Healthcare Provider Details

I. General information

NPI: 1720651904
Provider Name (Legal Business Name): GKS MILBURN CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2021
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W F AVE
MILBURN OK
73450-1504
US

IV. Provider business mailing address

PO BOX 67
MILBURN OK
73450-0067
US

V. Phone/Fax

Practice location:
  • Phone: 580-443-3533
  • Fax:
Mailing address:
  • Phone: 580-443-3533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN KHOURY
Title or Position: OWNER
Credential: DO
Phone: 580-775-2332