1619991783 NPI number — PROVISION IMAGING OF FIRST STREET

Table of content: (NPI 1619991783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619991783 NPI number — PROVISION IMAGING OF FIRST STREET

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVISION IMAGING OF FIRST STREET
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:
1619991783
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 NW EXPRESSWAY
Provider Second Line Business Mailing Address:
SUITE 1300
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-842-7768
Provider Business Mailing Address Fax Number:
405-842-7789

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4747 BELLAIRE BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BELLAIRE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77401-4527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-663-7672
Provider Business Practice Location Address Fax Number:
713-663-7677
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TRENT
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
MATT
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
405-842-7768

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , with the licence number:  R28949 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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