Provider Demographics
NPI:1942239702
Name:VANTAGE OPEN MRI LLC
Entity Type:Organization
Organization Name:VANTAGE OPEN MRI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:WICKERSHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-418-0900
Mailing Address - Street 1:3400 W HEFNER RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-5083
Mailing Address - Country:US
Mailing Address - Phone:405-418-0900
Mailing Address - Fax:405-418-0901
Practice Address - Street 1:3400 W HEFNER RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-5083
Practice Address - Country:US
Practice Address - Phone:405-418-0900
Practice Address - Fax:405-418-0901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK500522040Medicare ID - Type UnspecifiedMCR PART B - IDTF