Provider Demographics
NPI:1699745893
Name:OKLAHOMA SPINE HOSPITAL LLC
Entity type:Organization
Organization Name:OKLAHOMA SPINE HOSPITAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:LANE
Authorized Official - Last Name:BLAYLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-749-2700
Mailing Address - Street 1:PO BOX 803918
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-3918
Mailing Address - Country:US
Mailing Address - Phone:405-775-4241
Mailing Address - Fax:405-841-9385
Practice Address - Street 1:14101 PARKWAY COMMONS DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-6012
Practice Address - Country:US
Practice Address - Phone:405-749-2700
Practice Address - Fax:405-749-2743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2345282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK370206Medicare ID - Type Unspecified