Healthcare Provider Details

I. General information

NPI: 1912002684
Provider Name (Legal Business Name): JOE BRETT WELLS CRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 NE 4TH ST
GUYMON OK
73942-4838
US

IV. Provider business mailing address

301 NE 4TH ST
GUYMON OK
73942-4838
US

V. Phone/Fax

Practice location:
  • Phone: 580-338-4012
  • Fax: 580-338-4017
Mailing address:
  • Phone: 580-338-4012
  • Fax: 580-338-4017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number16-02033
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: