Healthcare Provider Details

I. General information

NPI: 1689888299
Provider Name (Legal Business Name): DAVENPORT ADULT CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 N. STRONG BLVD SUITE 300
MCALESTER OK
74501-1146
US

IV. Provider business mailing address

1609 N. STRONG BLVD SUITE 300
MCALESTER OK
74501-1146
US

V. Phone/Fax

Practice location:
  • Phone: 918-423-3400
  • Fax: 918-420-5051
Mailing address:
  • Phone: 918-423-3400
  • Fax: 918-420-5051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR0044227
License Number StateOK

VIII. Authorized Official

Name: KATHY C DAVENPORT
Title or Position: OWNER
Credential: ARNP
Phone: 918-423-3400