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General NPI Number Information
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NPI Number | 1710638820
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Entity Type | Organization
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Legal Business Name | GREEN COUNTRY PREVENTATIVE MEDICINE, LLC
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Dates
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Enumeration Date | 01/11/2022
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Last Update Date | 01/11/2022
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Provider Practice Location Address
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Address Line | 3202 S MEMORIAL DR STE 9
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City | TULSA
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State | OK
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Zip | 74145-1323
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Country | US
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Telephone | 918-704-0134
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Fax |
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Provider Business Mailing Address
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Address Line | 3202 S MEMORIAL DR STE 9
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City | TULSA
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State | OK
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Zip | 74145-1323
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN OWNER
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Name | ROBERT VALENTINE
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Credential | MD
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Telephone | 918-704-0134
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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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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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