Provider Demographics
NPI:1386305787
Name:EDMONDS, ROBERT BRENT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:BRENT
Last Name:EDMONDS
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:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74362-0669
Mailing Address - Country:US
Mailing Address - Phone:918-231-0021
Mailing Address - Fax:
Practice Address - Street 1:11607 S. 437 ROAD
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:OK
Practice Address - Zip Code:74352
Practice Address - Country:US
Practice Address - Phone:918-231-0021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator