1548407877 NPI number — HERBERT CALVIN PRINCE III MSHR

Table of content: HERBERT CALVIN PRINCE III MSHR (NPI 1548407877)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548407877 NPI number — HERBERT CALVIN PRINCE III MSHR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRINCE
Provider First Name:
HERBERT
Provider Middle Name:
CALVIN
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
MSHR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548407877
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1705 CRADDUCK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ADA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74820-9491
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23929 COUNTY ROAD 1560
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STONEWALL
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74871-6472
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-310-9000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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