Healthcare Provider Details

I. General information

NPI: 1881950970
Provider Name (Legal Business Name): NAMEN BOUMA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70-100 N. 31ST STREET
CLINTON OK
73601
US

IV. Provider business mailing address

717 N 5TH ST
WEATHERFORD OK
73096-2819
US

V. Phone/Fax

Practice location:
  • Phone: 580-323-6021
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: