1245403880 NPI number — RED RIVER MEDICAL, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245403880 NPI number — RED RIVER MEDICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RED RIVER MEDICAL, 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:
1245403880
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
414 E 124TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JENKS
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74037-4971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-633-3006
Provider Business Mailing Address Fax Number:
918-398-6072

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6802 S OLYMPIA AVE
Provider Second Line Business Practice Location Address:
STE 275
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74132-1823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-398-6077
Provider Business Practice Location Address Fax Number:
918-398-6072
Provider Enumeration Date:
04/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ARMSTRONG
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
MICHELLE
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
918-633-3006

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)





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