Provider First Line Business Practice Location Address: 
100 N UNIVERSITY DRIVE
    Provider Second Line Business Practice Location Address: 
ATTN: ATHLETIC TRAINING ROOM
    Provider Business Practice Location Address City Name: 
EDMOND
    Provider Business Practice Location Address State Name: 
OK
    Provider Business Practice Location Address Postal Code: 
73034
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
405-974-2188
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/12/2018