Provider Demographics
NPI:1588734925
Name:BREAST IMAGING OF OKLAHOMA, LLC
Entity type:Organization
Organization Name:BREAST IMAGING OF OKLAHOMA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-705-2712
Mailing Address - Street 1:2601 KELLEY POINTE PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-2996
Mailing Address - Country:US
Mailing Address - Phone:405-705-2712
Mailing Address - Fax:405-844-2610
Practice Address - Street 1:2601 KELLEY POINTE PKWY STE 101
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-2996
Practice Address - Country:US
Practice Address - Phone:405-705-2712
Practice Address - Fax:405-844-2610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty