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General NPI Number Information
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NPI Number | 1528589546
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Entity Type | Organization
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Legal Business Name | CLINIC AT WELLSTON
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Dates
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Enumeration Date | 06/29/2017
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Last Update Date | 08/23/2017
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Provider Practice Location Address
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Address Line | 309 WEST 2ND STREET SUITE B
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City | WELLSTON
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State | OK
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Zip | 74881
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Country | US
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Telephone | 405-356-3035
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Fax | 405-356-3035
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Provider Business Mailing Address
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Address Line | PO BOX 708
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City | WELLSTON
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State | OK
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Zip | 74881-0708
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Country | US
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Telephone | 918-906-9643
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Fax | 405-356-4199
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | MS. SISNE LIBRE' GROFF
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Credential |
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Telephone | 918-906-9643
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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