Healthcare Provider Details

I. General information

NPI: 1730447442
Provider Name (Legal Business Name): BRIAN COLE MUSGROVE R.D., L.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2012
Last Update Date: 04/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E CLARK BASS BLVD
MCALESTER OK
74501-4209
US

IV. Provider business mailing address

2207 SYCAMORE ST
MCALESTER OK
74501-3242
US

V. Phone/Fax

Practice location:
  • Phone: 405-570-0041
  • Fax: 918-421-8675
Mailing address:
  • Phone: 405-570-0041
  • Fax: 918-421-8675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1762
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number1762
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number1762
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number1762
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: