Healthcare Provider Details

I. General information

NPI: 1659310688
Provider Name (Legal Business Name): JANUICE MCCOLLUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 N PERKINS AVE
GUYMON OK
73942-5415
US

IV. Provider business mailing address

325 N PERKINS AVE
GUYMON OK
73942-5415
US

V. Phone/Fax

Practice location:
  • Phone: 580-338-8885
  • Fax: 580-338-8885
Mailing address:
  • Phone: 580-338-8885
  • Fax: 580-338-8885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMTO40040
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: