MEDICARE: HERBERT CALVIN PRINCE III MSHR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1548407877
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HERBERT CALVIN PRINCE III MSHR

Provider Business Mailing Address
First Line	:	1705 CRADDUCK RD
Second Line	:
City	:	ADA
State	:	OK
Zip	:	74820-9491
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	23929 COUNTY ROAD 1560
Second Line	:
City	:	STONEWALL
State	:	OK
Zip	:	74871-6472
Country	:	US
Telephone Number	:	405-310-9000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2009
Last Update Date	:	01/08/2009

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