1801825732 NPI number — ALTERNATIVE CARE CLINIC, INC.

Table of content: MICHAEL CHANG MD (NPI 1790985372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801825732 NPI number — ALTERNATIVE CARE CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALTERNATIVE CARE 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:
1801825732
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 56
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:
73075-0056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-238-7502
Provider Business Mailing Address Fax Number:
405-238-5269

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 S WALNUT ST
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:
73075-3811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-238-7502
Provider Business Practice Location Address Fax Number:
405-238-5269
Provider Enumeration Date:
07/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLIPPERTON
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
405-238-7502

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2116 , 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: 100831410A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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