Healthcare Provider Details

I. General information

NPI: 1114360278
Provider Name (Legal Business Name): SIRFREEBIRD EDWARDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2013
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 E ILLINOIS AVE
ENID OK
73701-7573
US

IV. Provider business mailing address

623 E ILLINOIS AVE
ENID OK
73701-7573
US

V. Phone/Fax

Practice location:
  • Phone: 580-977-8602
  • Fax:
Mailing address:
  • Phone: 580-977-8602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code102X00000X
TaxonomyPoetry Therapist
License Number
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: