Provider Demographics
NPI:1316127913
Name:RYLAN-JAGGER MEDICAL LLC
Entity type:Organization
Organization Name:RYLAN-JAGGER MEDICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DATHAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:JAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-513-7070
Mailing Address - Street 1:PO BOX 99112
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73199-0001
Mailing Address - Country:US
Mailing Address - Phone:405-513-7070
Mailing Address - Fax:405-513-7071
Practice Address - Street 1:523 S SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-6226
Practice Address - Country:US
Practice Address - Phone:405-513-7070
Practice Address - Fax:405-513-7071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-12
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care