1912094244 NPI number — SOUTH MOORE MEDICAL CLINIC, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912094244 NPI number — SOUTH MOORE MEDICAL CLINIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH MOORE MEDICAL CLINIC, PC
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:
1912094244
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14800 S WESTERN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73170-7112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-912-4900
Provider Business Mailing Address Fax Number:
405-912-4903

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14800 S WESTERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73170-7112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-912-4900
Provider Business Practice Location Address Fax Number:
405-912-4903
Provider Enumeration Date:
10/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LAYNE
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
405-912-4900

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 560202001 . This is a "DME NUMBER" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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