MEDICARE: CLINTON ALBERT PRIMEAUX

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	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1699660134
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLINTON ALBERT PRIMEAUX

Provider Business Mailing Address
First Line	:	8151 HIGHWAY 177
Second Line	:
City	:	RED ROCK
State	:	OK
Zip	:	74651-0348
Country	:	US
Telephone Number	:	580-723-4466
Fax Number	:

Provider Business Practice Location Address
First Line	:	8151 HIGHWAY 177
Second Line	:
City	:	RED ROCK
State	:	OK
Zip	:	74651-0348
Country	:	US
Telephone Number	:	580-723-4466
Fax Number	:	657-375-8606

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

Provider Enumeration Date	:	06/12/2025
Last Update Date	:	06/12/2025

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Directions to “ CLINTON ALBERT PRIMEAUX ” Practice Location

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