# PRAIRIE GARDENS MEDICAL LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1669080891
- **Authorized official:** DIANNE G TUPPER RN/OPAC (MANAGING PARTNER)
- **Authorized official phone:** (405) 742-8898

## Contact information

- **Practice address:** 1213 NW 122ND ST STE 401, OKLAHOMA CITY, OK 73114-7000
- **Practice address phone:** (405) 962-8123
- **Practice address fax:** (405) 962-8125
- **Mailing address:** 175 LARY LN, GUTHRIE, OK 73044-6542
- **Mailing address phone:** (405) 962-8123
- **Mailing address fax:** (405) 962-8125

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208D00000X | General Practice Physician | — | NULL | Yes |
| 208D00000X | General Practice Physician | — | — | Yes |

## Other

- **Enumeration date:** 07/14/2020
- **Last updated:** 09/16/2020