Provider Demographics
NPI:1649280702
Name:OKLAHOMA KIDNEY CENTER, INC.
Entity type:Organization
Organization Name:OKLAHOMA KIDNEY CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:405-682-0721
Mailing Address - Street 1:PO BOX 1513
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-1513
Mailing Address - Country:US
Mailing Address - Phone:405-321-5683
Mailing Address - Fax:405-329-0486
Practice Address - Street 1:2200 SW 59TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73119-7027
Practice Address - Country:US
Practice Address - Phone:405-682-0721
Practice Address - Fax:405-682-0757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2596174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100129880AMedicaid
OK100742430AMedicaid
OK400522127Medicare ID - Type UnspecifiedGROUP
OK100742430AMedicaid
OK447547952PMedicare PIN