Healthcare Provider Details

I. General information

NPI: 1043697741
Provider Name (Legal Business Name): KENNETH WARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 05/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 W GARY BLVD
CLINTON OK
73601-2727
US

IV. Provider business mailing address

1217 W GARY BLVD
CLINTON OK
73601-2727
US

V. Phone/Fax

Practice location:
  • Phone: 866-926-6552
  • Fax: 580-547-4076
Mailing address:
  • Phone: 866-926-6552
  • Fax: 580-547-4076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberL0062309
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: