Healthcare Provider Details

I. General information

NPI: 1699385278
Provider Name (Legal Business Name): VERDIGRIS VALLEY FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2020
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25965 S HIGHWAY 66 STE B
CLAREMORE OK
74019-2468
US

IV. Provider business mailing address

25965 S HIGHWAY 66 STE B
CLAREMORE OK
74019-2468
US

V. Phone/Fax

Practice location:
  • Phone: 918-550-0989
  • Fax:
Mailing address:
  • Phone: 918-269-3693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH LEE
Title or Position: OWNER/ EMPLOYEE
Credential: PA-C
Phone: 918-269-3693