Provider Demographics
NPI:1780018465
Name:COSMETIC CENTER OF TULSA LLC
Entity Type:Organization
Organization Name:COSMETIC CENTER OF TULSA LLC
Other - Org Name:FACE AND BODY MEDICAL AESTHETICS AND COSMETIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:A
Authorized Official - Last Name:CUSHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-298-8080
Mailing Address - Street 1:9906 RIVERSIDE PKWY
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-7409
Mailing Address - Country:US
Mailing Address - Phone:918-298-8080
Mailing Address - Fax:918-528-3841
Practice Address - Street 1:9906 RIVERSIDE PKWY
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-7409
Practice Address - Country:US
Practice Address - Phone:918-298-8080
Practice Address - Fax:918-528-3841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4362208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty