Healthcare Provider Details

I. General information

NPI: 1942459870
Provider Name (Legal Business Name): MIKE MCCONNELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 05/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 W DOGWOOD DR
POND CREEK OK
73766-9783
US

IV. Provider business mailing address

212 W DOGWOOD DR
POND CREEK OK
73766-9783
US

V. Phone/Fax

Practice location:
  • Phone: 580-231-5070
  • Fax:
Mailing address:
  • Phone: 580-231-5070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: