Healthcare Provider Details

I. General information

NPI: 1265658322
Provider Name (Legal Business Name): GREEN COUNTRY MEDICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 WILLOW
SOUTH COFFEYVILLE OK
74072
US

IV. Provider business mailing address

228 WILLOW
SOUTH COFFEYVILLE OK
74072
US

V. Phone/Fax

Practice location:
  • Phone: 918-255-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: SHERYL NEELY
Title or Position: RN
Credential:
Phone: 918-273-0140