Healthcare Provider Details

I. General information

NPI: 1245633429
Provider Name (Legal Business Name): TROY O'NEAL GLOVER CPRSS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 WEST MAIN ST.
DURANT OK
74701
US

IV. Provider business mailing address

873 CADDO HWY
CADDO OK
74729-4204
US

V. Phone/Fax

Practice location:
  • Phone: 580-924-7330
  • Fax:
Mailing address:
  • Phone: 580-924-7330
  • 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: