Healthcare Provider Details

I. General information

NPI: 1083215867
Provider Name (Legal Business Name): ROBERT FRANK TIPTON JR. PARA PROFESSIONAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 E CANADIAN AVE
VINITA OK
74301-3810
US

IV. Provider business mailing address

PO BOX 148
VINITA OK
74301-0148
US

V. Phone/Fax

Practice location:
  • Phone: 918-256-3424
  • Fax:
Mailing address:
  • Phone: 918-244-9877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberRC1804-1804
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: