Provider Demographics
NPI:1669405437
Name:NEW TRADITION CLINIC LLC
Entity type:Organization
Organization Name:NEW TRADITION CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIAH
Authorized Official - Middle Name:HELEN
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-806-6461
Mailing Address - Street 1:2021 S ELM PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-7031
Mailing Address - Country:US
Mailing Address - Phone:918-806-6461
Mailing Address - Fax:918-806-6710
Practice Address - Street 1:2021 S ELM PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-7031
Practice Address - Country:US
Practice Address - Phone:918-806-6461
Practice Address - Fax:918-806-6710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200070350AMedicaid
OK200070350AMedicaid
OK400522545Medicare ID - Type UnspecifiedMEDICARE NUMBER