MEDICARE: LAUREL GUILD

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	2255A2300X	Athletic Trainer	884	OK

General Provider Information

NPI Number	:	1215306238
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAUREL GUILD

Provider Business Mailing Address
First Line	:	536 SE ELMHURST AVE
Second Line	:
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006-8414
Country	:	US
Telephone Number	:	918-688-9608
Fax Number	:

Provider Business Practice Location Address
First Line	:	1902 SE WASHINGTON BLVD
Second Line	:
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006-6736
Country	:	US
Telephone Number	:	918-876-1482
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2015
Last Update Date	:	09/21/2015

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Directions to “ LAUREL GUILD ” Practice Location

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