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General NPI Number Information
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NPI Number | 1083850010
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Entity Type | Organization
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Legal Business Name | COSMOCOMET.LLC
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Dates
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Enumeration Date | 12/22/2008
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Last Update Date | 12/22/2008
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Provider Practice Location Address
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Address Line | 1222 N FLORENCE AVE
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City | CLAREMORE
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State | OK
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Zip | 74017-3147
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Country | US
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Telephone | 918-342-2528
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Fax | 918-342-2538
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Provider Business Mailing Address
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Address Line | 1222 N FLORENCE AVE
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City | CLAREMORE
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State | OK
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Zip | 74017-3147
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Country | US
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Telephone | 918-342-2528
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Fax | 918-342-2538
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | MR. MARK HABECK
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Credential |
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Telephone | 918-342-2528
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 3245
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License Number State | OK
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