Healthcare Provider Details

I. General information

NPI: 1497978753
Provider Name (Legal Business Name): GREEN COUNTRY MEDICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 E OSAGE AVE
NOWATA OK
74048-3638
US

IV. Provider business mailing address

712 E OSAGE AVE
NOWATA OK
74048-3638
US

V. Phone/Fax

Practice location:
  • Phone: 918-273-0140
  • Fax:
Mailing address:
  • Phone:
  • 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: LACEE HAYES
Title or Position: BILLING
Credential:
Phone: 918-273-0140