1063790202 NPI number — EAGLE COMMUNITY CLINIC LLC

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 1063790202 NPI number — EAGLE COMMUNITY CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAGLE COMMUNITY CLINIC LLC
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:
1063790202
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5995
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORMAN
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73070-5995
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-360-6764
Provider Business Mailing Address Fax Number:
405-360-6769

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13800 BENSON RD
Provider Second Line Business Practice Location Address:
202
Provider Business Practice Location Address City Name:
EDMOND
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73013-6422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-418-3077
Provider Business Practice Location Address Fax Number:
405-418-3076
Provider Enumeration Date:
07/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
PENICK
Authorized Official First Name:
BRANDON
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DIRECTOR OF REIMBURSEMENT
Authorized Official Telephone Number:
405-360-6764

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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