1639689185 NPI number — ZENA AREA COMMUNITY CLINIC, PLLC, MARCIA MATTHEWS SOLE MEMBER

Table of content: (NPI 1639689185)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639689185 NPI number — ZENA AREA COMMUNITY CLINIC, PLLC, MARCIA MATTHEWS SOLE MEMBER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ZENA AREA COMMUNITY CLINIC, PLLC, MARCIA MATTHEWS SOLE MEMBER
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:
ZENA AREA COMMUNITY CLINIC
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:
1639689185
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
52390 E 333 RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JAY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74346-5198
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-919-2272
Provider Business Mailing Address Fax Number:
918-786-2402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
37940 US HWY 59 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74346-7434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-964-6425
Provider Business Practice Location Address Fax Number:
918-786-2402
Provider Enumeration Date:
10/10/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MATTHEWS
Authorized Official First Name:
MARCIA
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
SOLE MEMBER OF S CORPORATION IN OK
Authorized Official Telephone Number:
918-919-2272

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  19451 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QU0200X , with the licence number: 19451 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 100124760A21 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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