Healthcare Provider Details

I. General information

NPI: 1770115933
Provider Name (Legal Business Name): COUNTRY CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

309 W 2ND ST STE B
WELLSTON OK
74881-9496
US

IV. Provider business mailing address

PO BOX 304
WELLSTON OK
74881-0304
US

V. Phone/Fax

Practice location:
  • Phone: 405-356-3001
  • Fax: 405-832-1144
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY GREEN
Title or Position: OWNER
Credential:
Phone: 405-356-3001