Basic Information
| Provider Information | |||||||||
| NPI: | 1902254204 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REX | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | ETHAN PATRICK | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 650 S PEORIA AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741204429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185879471 | ||||||||
| FaxNumber: | 9185601399 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 N DENVER AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741031806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185821200 | ||||||||
| FaxNumber: | 9185601399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2016 | ||||||||
| LastUpdateDate: | 05/26/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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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.