1528417409 NPI number — VALLEY FAMILY CLINIC INC

Table of content: (NPI 1528417409)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528417409 NPI number — VALLEY FAMILY CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VALLEY FAMILY CLINIC INC
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:
1528417409
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 BURR AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAULS VALLEY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73075-3848
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-238-4633
Provider Business Mailing Address Fax Number:
405-238-4690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 BURR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAULS VALLEY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73075-3848
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-238-4633
Provider Business Practice Location Address Fax Number:
405-238-4690
Provider Enumeration Date:
06/10/2016

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
405-238-4633

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , 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: 1467593210 . This is a "NPI" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 1730155904 . This is a "NPI" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 200162480B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100131280B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1972531465 . This is a "NPI" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100124310A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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