Healthcare Provider Details

I. General information

NPI: 1649951211
Provider Name (Legal Business Name): ELMBROOK CLINICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1908 12TH AVE NW SUITE E
ARDMORE OK
73401-1255
US

IV. Provider business mailing address

1908 12TH AVE NW SUITE E
ARDMORE OK
73401-1255
US

V. Phone/Fax

Practice location:
  • Phone: 580-226-3055
  • Fax: 580-226-3121
Mailing address:
  • Phone: 580-226-3055
  • Fax: 580-226-3121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. TOM C COBLE
Title or Position: SOLE MEMBER/INITIAL MANAGER
Credential:
Phone: 580-220-7093