=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679045439
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRISTOW ENDEAVOR HEALTHCARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2018
-----------------------------------------------------
Last Update Date | 10/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 OK-33 TRUCK
-----------------------------------------------------
City | DRUMRIGHT
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-701-2302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 OK-33 TRUCK
-----------------------------------------------------
City | DRUMRIGHT
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JAN ELLEN WINTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 918-367-2215
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------