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General NPI Number Information
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NPI Number | 1962991919
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Entity Type | Organization
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Legal Business Name | LOCAL MED LLC
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Dates
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Enumeration Date | 05/04/2018
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Last Update Date | 02/28/2019
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Provider Practice Location Address
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Address Line | 402 N BROADWAY ST
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City | WALTERS
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State | OK
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Zip | 73572
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Country | US
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Telephone | 580-252-5100
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Fax | 580-252-5102
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Provider Business Mailing Address
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Address Line | 402 N BROADWAY ST
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City | WALTERS
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State | OK
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Zip | 73572-1230
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Country | US
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Telephone | 580-875-5622
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Fax | 580-252-5102
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | DR. JAY LANCE GREGSTON
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Credential | MD
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Telephone | 580-875-5622
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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 | OK
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