Basic Information
| Provider Information | |||||||||
| NPI: | 1013520733 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTER FOR JOINT RELIEF LLC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10325 GREENBRIAR PL STE B | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731597647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057597719 | ||||||||
| FaxNumber: | 4057597718 | ||||||||
| Practice Location | |||||||||
| Address1: | 10325 GREENBRIAR PL STE B | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731597647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057597719 | ||||||||
| FaxNumber: | 4057597718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2020 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MANNING | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4057061266 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MSPT | ||||||||
| NPICertificationDate: | 08/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Preventive Medicine/Occupational Environmental Medicine | 208100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.