1073212387 NPI number — VCG OKLAHOMA LLC

Table of content: (NPI 1073212387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073212387 NPI number — VCG OKLAHOMA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VCG OKLAHOMA LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073212387
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 222132
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75222-2132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-787-7609
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4520 S HARVARD AVE STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74135-2900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-508-7333
Provider Business Practice Location Address Fax Number:
918-551-6113
Provider Enumeration Date:
02/24/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WALKER
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
214-491-0041

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)