Provider Demographics
NPI:1922439421
Name:GREG CLEMENT AGENCY
Entity Type:Organization
Organization Name:GREG CLEMENT AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNEER/AGENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLEMENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-795-3064
Mailing Address - Street 1:PO BOX 846
Mailing Address - Street 2:
Mailing Address - City:MADILL
Mailing Address - State:OK
Mailing Address - Zip Code:73446
Mailing Address - Country:US
Mailing Address - Phone:580-795-3064
Mailing Address - Fax:
Practice Address - Street 1:509 N 1ST ST
Practice Address - Street 2:
Practice Address - City:MADILL
Practice Address - State:OK
Practice Address - Zip Code:73446-1406
Practice Address - Country:US
Practice Address - Phone:580-795-3064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7598553251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)