Provider Demographics
NPI:1942703665
Name:NORTHEAST OKLAHOMA SPINE AND SPORTS LLC
Entity Type:Organization
Organization Name:NORTHEAST OKLAHOMA SPINE AND SPORTS LLC
Other - Org Name:NORTHEAST OKLAHOMA SPINE AND SPORTS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:BILLY
Authorized Official - Last Name:WILLITS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-518-5013
Mailing Address - Street 1:6048A S SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-9212
Mailing Address - Country:US
Mailing Address - Phone:918-518-5013
Mailing Address - Fax:918-417-7864
Practice Address - Street 1:6048A S SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-9212
Practice Address - Country:US
Practice Address - Phone:918-518-5013
Practice Address - Fax:918-417-7864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty