Provider Demographics
NPI:1922057264
Name:KOLLOCK, ROGER OLEN JR (ATC)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:OLEN
Last Name:KOLLOCK
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-7263
Mailing Address - Country:US
Mailing Address - Phone:423-943-1528
Mailing Address - Fax:
Practice Address - Street 1:2405 S 14TH ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-7263
Practice Address - Country:US
Practice Address - Phone:423-943-1528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKAT10842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer