Provider Demographics
NPI:1932670791
Name:RISENHOOVER, CHARLIE MAC
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:MAC
Last Name:RISENHOOVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 E EUFAULA ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-5806
Mailing Address - Country:US
Mailing Address - Phone:405-675-1376
Mailing Address - Fax:
Practice Address - Street 1:1501 NE 11TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-2605
Practice Address - Country:US
Practice Address - Phone:405-230-1158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist