Provider Demographics
NPI:1912983719
Name:PONCA CITY OPEN MRI, LLC
Entity Type:Organization
Organization Name:PONCA CITY OPEN MRI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-762-6740
Mailing Address - Street 1:2112 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-1829
Mailing Address - Country:US
Mailing Address - Phone:580-762-6740
Mailing Address - Fax:580-762-9627
Practice Address - Street 1:2112 N 14TH ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-1829
Practice Address - Country:US
Practice Address - Phone:580-762-6740
Practice Address - Fax:580-762-9627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS7187533301Medicaid
OK100836750AMedicaid
900522033Medicare ID - Type Unspecified