| Integrated Renegade, Llc | |
|
1264 E 139th Pl Glenpool OK 74033-3125 | |
| (918) 321-0697 | |
| Not Available |
| Full Name | Integrated Renegade, Llc |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 1264 E 139th Pl, Glenpool, Oklahoma |
| Authorized Official Name and Position | Petra Russell (OWNER) |
| Authorized Official Contact | 9183210697 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Integrated Renegade, Llc 1264 E 139th Pl Glenpool OK 74033-3125 Ph: () - | Integrated Renegade, Llc 1264 E 139th Pl Glenpool OK 74033-3125 Ph: (918) 321-0697 |
| NPI Number | 1366223265 |
|---|---|
| Provider Enumeration Date | 10/09/2023 |
| Last Update Date | 10/09/2023 |
| Certification Date | 10/08/2023 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1366223265 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
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