Provider Demographics
NPI:1528589546
Name:CLINIC AT WELLSTON
Entity Type:Organization
Organization Name:CLINIC AT WELLSTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SISNE
Authorized Official - Middle Name:LIBRE'
Authorized Official - Last Name:GROFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-906-9643
Mailing Address - Street 1:PO BOX 708
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OK
Mailing Address - Zip Code:74881-0708
Mailing Address - Country:US
Mailing Address - Phone:918-906-9643
Mailing Address - Fax:405-356-4199
Practice Address - Street 1:309 WEST 2ND STREET
Practice Address - Street 2:SUITE B
Practice Address - City:WELLSTON
Practice Address - State:OK
Practice Address - Zip Code:74881
Practice Address - Country:US
Practice Address - Phone:405-356-3035
Practice Address - Fax:405-356-3035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-29
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200002570AMedicaid
OK100227020AMedicaid