Basic Information
Provider Information
NPI: 1114952025
EntityType: 2
ReplacementNPI:  
OrganizationName: ESEC LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
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OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 268867
Address2:  
City: OKLAHOMA CITY
State: OK
PostalCode: 731268867
CountryCode: US
TelephoneNumber: 4058424850
FaxNumber: 4058482425
Practice Location
Address1: 3705 NW 63RD ST
Address2: STE 100
City: OKLAHOMA CITY
State: OK
PostalCode: 731161905
CountryCode: US
TelephoneNumber: 4054633484
FaxNumber: 4056084259
Other Information
ProviderEnumerationDate: 07/11/2006
LastUpdateDate: 11/19/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: ARVIEUX
AuthorizedOfficialFirstName: JOLENE
AuthorizedOfficialMiddleName: J
AuthorizedOfficialTitleorPosition: ADMINISTRATOR
AuthorizedOfficialTelephone: 4054633484
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MRS.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QA1903X0079OKY Ambulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical

ID Information
IDTypeStateIssuerDescription
200089950A05OK MEDICAID
P0031745201OKMEDICARE RAILROADOTHER
770385501OKAETNAOTHER


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