Provider Demographics
NPI:1144363094
Name:ASPEN CHILDREN'S CLINIC OF BROKEN ARROW INC.
Entity type:Organization
Organization Name:ASPEN CHILDREN'S CLINIC OF BROKEN ARROW INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SURESH
Authorized Official - Middle Name:
Authorized Official - Last Name:BHARANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-455-4140
Mailing Address - Street 1:3300 S ASPEN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-7501
Mailing Address - Country:US
Mailing Address - Phone:918-455-4140
Mailing Address - Fax:
Practice Address - Street 1:3300 S ASPEN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-7501
Practice Address - Country:US
Practice Address - Phone:918-455-4140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12973261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care