Provider Demographics
NPI:1750466587
Name:MCI DIAGNOSTIC CENTER, LLC
Entity Type:Organization
Organization Name:MCI DIAGNOSTIC CENTER, LLC
Other - Org Name:MCI DIAGNOSTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:469-485-2382
Mailing Address - Street 1:7018 S UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3907
Mailing Address - Country:US
Mailing Address - Phone:918-744-1001
Mailing Address - Fax:918-744-9729
Practice Address - Street 1:1155 KAS DR STE 180
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-1970
Practice Address - Country:US
Practice Address - Phone:469-485-2382
Practice Address - Fax:918-744-9729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291U00000X
OK2-S-2821332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200031560BMedicaid
OK200031560BMedicaid
OKOKB5944Medicare PIN
OK500522021Medicare PIN