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General NPI Number Information
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NPI Number | 1093240749
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Entity Type | Organization
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Legal Business Name | GREEN'S COUNTRY CLINIC, LLC
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Dates
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Enumeration Date | 05/01/2017
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Last Update Date | 05/01/2017
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Provider Practice Location Address
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Address Line | 223 E BLACKWELL AVE
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City | BLACKWELL
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State | OK
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Zip | 74631-2909
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Country | US
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Telephone | 580-363-0943
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Fax |
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Provider Business Mailing Address
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Address Line | 223 E BLACKWELL AVE
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City | BLACKWELL
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State | OK
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Zip | 74631-2909
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN ASSISTANT
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Name | PHIL GREEN
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Credential | PA-C
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Telephone | 580-363-0943
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 800
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License Number State | OK
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