Healthcare Provider Details

I. General information

NPI: 1528589546
Provider Name (Legal Business Name): CLINIC AT WELLSTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 08/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 WEST 2ND STREET SUITE B
WELLSTON OK
74881
US

IV. Provider business mailing address

PO BOX 708
WELLSTON OK
74881-0708
US

V. Phone/Fax

Practice location:
  • Phone: 405-356-3035
  • Fax: 405-356-3035
Mailing address:
  • Phone: 918-906-9643
  • Fax: 405-356-4199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. SISNE LIBRE' GROFF
Title or Position: OWNER/OPERATOR
Credential:
Phone: 918-906-9643