Provider Demographics
NPI:1881805232
Name:OKLAHOMA BREAST CARE CENTER LLC
Entity type:Organization
Organization Name:OKLAHOMA BREAST CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-755-2273
Mailing Address - Street 1:13509 N MERIDIAN AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8396
Mailing Address - Country:US
Mailing Address - Phone:405-755-2273
Mailing Address - Fax:405-751-3505
Practice Address - Street 1:13509 N MERIDIAN AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8396
Practice Address - Country:US
Practice Address - Phone:405-755-2273
Practice Address - Fax:405-751-3505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherEIN