Healthcare Provider Details

I. General information

NPI: 1386114999
Provider Name (Legal Business Name): MELODY DEDMON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 11/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 E LINCOLN RD
IDABEL OK
74745-7337
US

IV. Provider business mailing address

1401 CLEVELAND ST
IDABEL OK
74745-8005
US

V. Phone/Fax

Practice location:
  • Phone: 580-286-2600
  • Fax:
Mailing address:
  • Phone: 479-234-6433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2370
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: