Healthcare Provider Details

I. General information

NPI: 1134748619
Provider Name (Legal Business Name): TAMMY GORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 04/14/2020
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 W 2ND ST
WELLSTON OK
74881-9496
US

IV. Provider business mailing address

335414 E 880 RD
WELLSTON OK
74881-8247
US

V. Phone/Fax

Practice location:
  • Phone: 405-635-5097
  • Fax:
Mailing address:
  • Phone: 405-635-5097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number144501
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: