=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659738953
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALTUS MINOR EMERGENCY & FAMILY PRACTICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2016
-----------------------------------------------------
Last Update Date | 03/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 916 N MAIN ST
-----------------------------------------------------
City | ALTUS
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73521-3118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-318-0229
-----------------------------------------------------
Fax | 580-480-0044
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 916 N MAIN ST
-----------------------------------------------------
City | ALTUS
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73521-3118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-318-0229
-----------------------------------------------------
Fax | 580-480-0044
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. BRIDGET MOSS
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 580-318-0229
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------