Healthcare Provider Details

I. General information

NPI: 1558672766
Provider Name (Legal Business Name): MR. HODALEE SEWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E ILLINOIS AVE
VINITA OK
74301-3202
US

IV. Provider business mailing address

401 S MUSKOGEE AVE
CLAREMORE OK
74017-8021
US

V. Phone/Fax

Practice location:
  • Phone: 918-256-9961
  • Fax:
Mailing address:
  • Phone: 850-254-5426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: