Healthcare Provider Details

I. General information

NPI: 1295243749
Provider Name (Legal Business Name): BRISTOW ENDEAVOR HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2340 E. MAIN STREET
CUSHING OK
74023
US

IV. Provider business mailing address

700 W. 7TH STREET
BRISTOW OK
74010
US

V. Phone/Fax

Practice location:
  • Phone: 918-225-6904
  • Fax: 918-225-4559
Mailing address:
  • Phone: 918-367-2215
  • Fax: 918-367-9190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JAN E. WINTER
Title or Position: CEO
Credential:
Phone: 918-367-2215