Provider Demographics
NPI:1184341489
Name:PERIGON PROSTATE CENTER LLC
Entity type:Organization
Organization Name:PERIGON PROSTATE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:PRENTICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-650-4786
Mailing Address - Street 1:5600 N MAY AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4275
Mailing Address - Country:US
Mailing Address - Phone:405-418-2200
Mailing Address - Fax:405-418-2901
Practice Address - Street 1:100 SE 59TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73129-3616
Practice Address - Country:US
Practice Address - Phone:408-418-2200
Practice Address - Fax:405-418-2901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile