Healthcare Provider Details

I. General information

NPI: 1922467505
Provider Name (Legal Business Name): STOVER FAMILY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2016
Last Update Date: 02/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 VETERANS WAY
BROKEN BOW OK
74728
US

IV. Provider business mailing address

813 VETERANS WAY
BROKEN BOW OK
74728
US

V. Phone/Fax

Practice location:
  • Phone: 580-584-6600
  • Fax: 580-584-6603
Mailing address:
  • Phone: 580-584-6600
  • Fax: 580-584-6603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberR0096200
License Number StateOK

VIII. Authorized Official

Name: REBECCA RENEE STOVER
Title or Position: OWNER
Credential: RN, NP-C
Phone: 580-584-6600