1497872717 NPI number — FAMILY CARE CENTERS OF OKLAHOMA, LLC

Table of content: (NPI 1497872717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497872717 NPI number — FAMILY CARE CENTERS OF OKLAHOMA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY CARE CENTERS OF OKLAHOMA, LLC
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:
6
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:
1497872717
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 72250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORPUS CHRISTI
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78472-2250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-852-9521
Provider Business Mailing Address Fax Number:
361-855-1454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 E CONNER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRLAND
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-676-3685
Provider Business Practice Location Address Fax Number:
918-676-3008
Provider Enumeration Date:
03/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FOLMAR
Authorized Official First Name:
SHARIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
361-852-9521

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH5803-5803 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 313M00000X , with the licence number: NH5803-5803 , 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: 37E258 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 37-5515 . This is a "MEDICARE CCN" identifier . This identifiers is of the category "OTHER".




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