Provider Demographics
NPI:1043501034
Name:VIDAURRI, LUPE NICHOLAS (BA CRIMINAL JUSTIC)
Entity type:Individual
Prefix:MR
First Name:LUPE
Middle Name:NICHOLAS
Last Name:VIDAURRI
Suffix:
Gender:M
Credentials:BA CRIMINAL JUSTIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 FRISCO AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73601-3320
Mailing Address - Country:US
Mailing Address - Phone:580-323-9100
Mailing Address - Fax:
Practice Address - Street 1:703 FRISCO AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-3320
Practice Address - Country:US
Practice Address - Phone:580-323-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker