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General NPI Number Information
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NPI Number | 1285068791
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Entity Type | Organization
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Legal Business Name | ST. MADRON MEDICAL CLINIC
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Dates
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Enumeration Date | 09/03/2013
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Last Update Date | 08/06/2015
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Provider Practice Location Address
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Address Line | 205 E. RAY FINE BLVD ST. 6
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City | ROLAND
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State | OK
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Zip | 74954
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Country | US
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Telephone | 918-503-6235
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Fax | 918-398-0637
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Provider Business Mailing Address
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Address Line | 303 TOWSON AVE.
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City | FORT SMITH
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State | AR
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Zip | 72901
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Country | US
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Telephone | 918-503-6235
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Fax | 918-398-0637
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Authorized Official
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Title or Position | OWNER
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Name | DARREN BREWER
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Credential |
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Telephone | 918-503-6235
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 17754
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License Number State | OK
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