MEDICARE: MALCOLM COUNSELING AND DUI SERVICES, LLC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	698	OK

General Provider Information

NPI Number	:	1194157966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MALCOLM COUNSELING AND DUI SERVICES, LLC.

Provider Business Mailing Address
First Line	:	4500 N LINCOLN BLVD
Second Line	:	SUITE 105
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73105-3406
Country	:	US
Telephone Number	:	405-601-5553
Fax Number	:

Provider Business Practice Location Address
First Line	:	4500 N LINCOLN BLVD
Second Line	:	SUITE 105
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73105-3406
Country	:	US
Telephone Number	:	405-601-5553
Fax Number	:

Authorized Official
Title or Position	:	OWNER, COUNSELOR, DUI ASSESSOR
Name	:	MR. LAMONT RUDOLPH MALCOLM
Credential	:	LADC, CM-III
Telephone Number	:	405-637-5935

Provider Enumeration Date	:	08/05/2013
Last Update Date	:	08/05/2013

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