Healthcare Provider Details

I. General information

NPI: 1871028191
Provider Name (Legal Business Name): MR. GREGORY MEADOWS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2017
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 TARTAN CT
ST AUGUSTINE FL
32092-3245
US

IV. Provider business mailing address

23 TARTAN CT
ST AUGUSTINE FL
32092-3245
US

V. Phone/Fax

Practice location:
  • Phone: 918-814-0415
  • Fax:
Mailing address:
  • Phone: 918-814-0415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: