1699953687 NPI number — FAMILY CLINIC OF WELEETKA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699953687 NPI number — FAMILY CLINIC OF WELEETKA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY CLINIC OF WELEETKA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FAMILY CLINIC OF WELEETKA
Provider Other Organization Name Type Code:
5
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:
1699953687
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 337
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WELEETKA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74880-0337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-786-2248
Provider Business Mailing Address Fax Number:
405-786-2006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 W. 9TH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WELEETKA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-786-2248
Provider Business Practice Location Address Fax Number:
405-786-2006
Provider Enumeration Date:
02/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PARKER
Authorized Official First Name:
JAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
405-786-2248

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  373819 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100743630B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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