Basic Information
| Provider Information | |||||||||
| NPI: | 1295243749 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRISTOW ENDEAVOR HEALTHCARE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CIMARRON HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 700 W. 7TH STREET | ||||||||
| Address2: | |||||||||
| City: | BRISTOW, | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183672215 | ||||||||
| FaxNumber: | 9183679190 | ||||||||
| Practice Location | |||||||||
| Address1: | 2340 E. MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | CUSHING, | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182256904 | ||||||||
| FaxNumber: | 9182254559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2018 | ||||||||
| LastUpdateDate: | 05/29/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WINTER | ||||||||
| AuthorizedOfficialFirstName: | JAN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9183672215 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BRISTOW ENDEAVOR HEALTHCARE, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.