Provider Demographics
NPI:1730703596
Name:SIMMONS, KEVIN LEE (CIO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEE
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:CIO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10700 S CHOCTAW RD
Mailing Address - Street 2:
Mailing Address - City:NEWALLA
Mailing Address - State:OK
Mailing Address - Zip Code:74857-7962
Mailing Address - Country:US
Mailing Address - Phone:405-481-0789
Mailing Address - Fax:
Practice Address - Street 1:10700 S CHOCTAW RD
Practice Address - Street 2:
Practice Address - City:NEWALLA
Practice Address - State:OK
Practice Address - Zip Code:74857-7962
Practice Address - Country:US
Practice Address - Phone:405-481-0789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-07
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty