=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366740805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOLD BISON ENTERPRISES, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2011
-----------------------------------------------------
Last Update Date | 03/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6105 SE NOWATA ROAD SUITE 107
-----------------------------------------------------
City | BARTLESVILLE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74006-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-766-1151
-----------------------------------------------------
Fax | 918-335-3795
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 118 FLEETWOOD PL
-----------------------------------------------------
City | BARTLESVILLE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74006-8315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-766-1151
-----------------------------------------------------
Fax | 918-333-3187
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KIMBERLY R. MASHUNKASHEY
-----------------------------------------------------
Credential | M.A., CCC-SLP
-----------------------------------------------------
Telephone | 918-766-1151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 2734
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------