Provider Demographics
NPI:1730447442
Name:MUSGROVE, BRIAN COLE (RD, LD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:COLE
Last Name:MUSGROVE
Suffix:
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2207 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-3242
Mailing Address - Country:US
Mailing Address - Phone:405-570-0041
Mailing Address - Fax:918-421-8675
Practice Address - Street 1:1 E CLARK BASS BLVD
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4209
Practice Address - Country:US
Practice Address - Phone:405-570-0041
Practice Address - Fax:918-421-8675
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1762133V00000X, 133VN1004X, 133VN1005X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic