Healthcare Provider Details

I. General information

NPI: 1982896544
Provider Name (Legal Business Name): DYCUS-CAMP CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N SERVICE RD
MOORE OK
73160-4945
US

IV. Provider business mailing address

320 N SERVICE RD
MOORE OK
73160-4945
US

V. Phone/Fax

Practice location:
  • Phone: 405-794-4474
  • Fax:
Mailing address:
  • Phone: 405-794-4474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. SHELLEY R SHELTON
Title or Position: OFFICE MANAGER
Credential:
Phone: 405-794-4474