Provider Demographics
NPI:1881641355
Name:EVIDENT HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:EVIDENT HEALTH SERVICES, LLC
Other - Org Name:EVIDENTCARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:AUSTIN
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:405-713-4990
Mailing Address - Street 1:3366 NW EXPRESSWAY
Mailing Address - Street 2:SUITE 520
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4444
Mailing Address - Country:US
Mailing Address - Phone:405-713-4990
Mailing Address - Fax:405-713-4992
Practice Address - Street 1:3366 NW EXPRESSWAY
Practice Address - Street 2:SUITE 520
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4444
Practice Address - Country:US
Practice Address - Phone:405-713-4990
Practice Address - Fax:405-713-4992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20972261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKC95271Medicare UPIN