Provider Demographics
NPI:1518395128
Name:WOMACK, MICHAEL KEVIN SR
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEVIN
Last Name:WOMACK
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1385
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-1385
Mailing Address - Country:US
Mailing Address - Phone:870-810-0003
Mailing Address - Fax:
Practice Address - Street 1:206 BURKLE AVE
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2208
Practice Address - Country:US
Practice Address - Phone:870-810-0003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator