Healthcare Provider Details

I. General information

NPI: 1427476548
Provider Name (Legal Business Name): RONNIE STEVENS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2014
Last Update Date: 04/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 WASHUNGA ST
HOMINY OK
74035-6524
US

IV. Provider business mailing address

219 WASHUNGA ST
HOMINY OK
74035-6524
US

V. Phone/Fax

Practice location:
  • Phone: 918-885-4020
  • Fax:
Mailing address:
  • Phone: 918-885-4020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: