=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730428939
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AFFORDABLE WEIGHT LOSS AND PAIN MANAGEMENT CLINIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2013
-----------------------------------------------------
Last Update Date | 02/07/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 810 W BROADWAY ST
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401-4527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-224-2669
-----------------------------------------------------
Fax | 580-319-5294
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 810 W BROADWAY ST
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401-4527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-224-2669
-----------------------------------------------------
Fax | 580-319-5294
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JARRETT GORDON GREGORY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 580-224-2669
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | 13611
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------