1093008385 NPI number — ECLIPSE THERAPY SOLUTION

Table of content: (NPI 1093008385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093008385 NPI number — ECLIPSE THERAPY SOLUTION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ECLIPSE THERAPY SOLUTION
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:
NONE
Provider Other Organization Name Type Code:
5
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:
1093008385
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 268946
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73126-8946
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-601-6767
Provider Business Mailing Address Fax Number:
405-601-6761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3112 COOKE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73179-2401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-601-6767
Provider Business Practice Location Address Fax Number:
405-601-6761
Provider Enumeration Date:
05/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
NUTT
Authorized Official First Name:
TREVOR
Authorized Official Middle Name:
Authorized Official Title or Position:
PRINCIPAL
Authorized Official Telephone Number:
405-601-6767

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200402780A . This is a "OHCA OKLAHOMA MEDICAID" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 1093008385 . This is a "BCBS OF OKLAHOMA" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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