Basic Information
| Provider Information | |||||||||
| NPI: | 1871154807 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DORRIS | ||||||||
| FirstName: | KALEB | ||||||||
| MiddleName: | BENJAMIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7777 S LEWIS AVE | ||||||||
| Address2: | PMB 71-0412 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74171 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6216 S LEWIS AVE STE 180 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741361077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189607852 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2019 | ||||||||
| LastUpdateDate: | 06/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.