Provider Demographics
NPI:1104549427
Name:BROKEN ARROW PAIN SPECIALIST, LLC
Entity type:Organization
Organization Name:BROKEN ARROW PAIN SPECIALIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LADD
Authorized Official - Middle Name:
Authorized Official - Last Name:ATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-361-4284
Mailing Address - Street 1:1129 S ASPEN AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-4859
Mailing Address - Country:US
Mailing Address - Phone:539-367-1253
Mailing Address - Fax:539-367-3311
Practice Address - Street 1:1129 S ASPEN AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-4859
Practice Address - Country:US
Practice Address - Phone:539-367-1253
Practice Address - Fax:539-367-3311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200121490AMedicaid