Provider Demographics
NPI:1639843980
Name:ELMORE, CALVIN JACOB
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:JACOB
Last Name:ELMORE
Suffix:
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 1:217 PONT MIRABEAU CIR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-9388
Mailing Address - Country:US
Mailing Address - Phone:405-240-2481
Mailing Address - Fax:
Practice Address - Street 1:14828 SERENITA AVE.
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-7313
Practice Address - Country:US
Practice Address - Phone:405-838-1994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician