Provider Demographics
NPI:1386947604
Name:SOUTHCREST LLC
Entity type:Organization
Organization Name:SOUTHCREST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-892-9813
Mailing Address - Street 1:7100 COMMERCE WAY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2829
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8803 S 101ST EAST AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5726
Practice Address - Country:US
Practice Address - Phone:918-294-2100
Practice Address - Fax:918-294-2110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-08
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0063261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKPENDINGMedicaid
OKOKB6010Medicare PIN