Provider Demographics
NPI:1255821005
Name:SOUTH TULSA PAIN MANAGEMENT LLC.
Entity type:Organization
Organization Name:SOUTH TULSA PAIN MANAGEMENT LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-520-9692
Mailing Address - Street 1:12345 S MEMORIAL DR STE 111
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-2570
Mailing Address - Country:US
Mailing Address - Phone:918-520-9692
Mailing Address - Fax:
Practice Address - Street 1:12345 S MEMORIAL DR STE 106
Practice Address - Street 2:
Practice Address - City:BIXBY
Practice Address - State:OK
Practice Address - Zip Code:74008
Practice Address - Country:US
Practice Address - Phone:918-520-9692
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-17
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty