1336697432 NPI number — GRAND PRIMARY CARE CLINICS

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 1336697432 NPI number — GRAND PRIMARY CARE CLINICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND PRIMARY CARE CLINICS
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:
Provider Other Organization Name Type Code:
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:
1336697432
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5401 N PORTLAND AVE
Provider Second Line Business Mailing Address:
SUITE 270
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73112-2121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-605-0108
Provider Business Mailing Address Fax Number:
405-463-0120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5401 N PORTLAND AVE
Provider Second Line Business Practice Location Address:
SUITE 270
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73112-2121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-605-0108
Provider Business Practice Location Address Fax Number:
405-463-0120
Provider Enumeration Date:
09/17/2016

Additional Information

Authorized Official

Authorized Official Last Name:
HUNTER
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
405-418-2929

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , 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: PENDING , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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