Facts
- Status
- A
- Type
- Individual
- Enumeration date
- 2015-07-01
- Last updated
- 2023-05-11
Specialties
Licenses
The registry row did not include a license.
Location
- Practice location
- 105365 S HIGHWAY 102
- City
- MCLOUD OK
- Postal code
- 748513051
- Phone
- 405-988-2073
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
The OIG NPI list is not in this build yet. Confirm on OIG's search.
Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.