Provider Demographics
NPI:1790969053
Name:SOUTH TULSA PERFORMANCE HEALTH
Entity Type:Organization
Organization Name:SOUTH TULSA PERFORMANCE HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-949-6622
Mailing Address - Street 1:7112 S MINGO RD STE 101
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-3267
Mailing Address - Country:US
Mailing Address - Phone:918-949-6622
Mailing Address - Fax:918-872-9913
Practice Address - Street 1:7112 S MINGO RD STE 101
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-3267
Practice Address - Country:US
Practice Address - Phone:918-949-6622
Practice Address - Fax:918-872-9913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3785261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKB5131Medicare PIN
OK700704Medicare PIN
OK700705Medicare PIN