1528336252 NPI number — AWENASA MANAGEMENT LLC

Table of content: (NPI 1528336252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528336252 NPI number — AWENASA MANAGEMENT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AWENASA MANAGEMENT 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:
FAMILY CARE CENTER OF FAIRLAND
Provider Other Organization Name Type Code:
3
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:
1528336252
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5430 W 640
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHOUTEAU
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74337-5504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-476-6642
Provider Business Mailing Address Fax Number:
918-476-4679

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 E CONNER AVE.
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:
74343-0336
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:
12/08/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MAHURIN
Authorized Official First Name:
TERESA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
918-476-6642

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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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