Healthcare Provider Details

I. General information

NPI: 1629254651
Provider Name (Legal Business Name): ANGESL HEALTH CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 E 5TH ST
PAWHUSKA OK
74056-5204
US

IV. Provider business mailing address

230 E 5TH ST
PAWHUSKA OK
74056-5204
US

V. Phone/Fax

Practice location:
  • Phone: 918-287-2100
  • Fax: 918-287-2113
Mailing address:
  • Phone: 918-287-2100
  • Fax: 918-287-2113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: THERESA A FLOWERETTE
Title or Position: DIRECTOR
Credential: RN
Phone: 918-287-2100