1912568304 NPI number — COMMUNITY FAMILY MEDICAL CLINIC, LLC.

Table of content: BROOKS MICHAEL WHALEN PA (NPI 1245506799)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912568304 NPI number — COMMUNITY FAMILY MEDICAL CLINIC, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY FAMILY MEDICAL 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:
1912568304
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O BOX 988
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROLAND
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74954
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-427-7581
Provider Business Mailing Address Fax Number:
918-427-7798

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1202 FORT STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARLING
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-427-7581
Provider Business Practice Location Address Fax Number:
918-427-7798
Provider Enumeration Date:
06/26/2019

Additional Information

Authorized Official

Authorized Official Last Name:
MATLOCK
Authorized Official First Name:
TY
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
479-561-8811

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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