1952477093 NPI number — URGENT CARE CLINIC OF ATOKA, PC

Table of content: (NPI 1952477093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952477093 NPI number — URGENT CARE CLINIC OF ATOKA, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
URGENT CARE CLINIC OF ATOKA, 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:
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:
1952477093
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1510 S. VIRGINIA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATOKA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74525-3246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-889-6621
Provider Business Mailing Address Fax Number:
580-889-3602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1510 S. VIRGINIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATOKA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74525-3246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-889-6621
Provider Business Practice Location Address Fax Number:
580-889-3602
Provider Enumeration Date:
11/28/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EMERSON
Authorized Official First Name:
NOEL
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
580-889-6621

Provider Taxonomy Codes

  • Taxonomy code: 204D00000X , with the licence number:  1806 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 3521 , 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: 100733090C , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".