| |
825 Ne 10th St Oupb5200 Okc OK 73104 | |
(405) 271-7867 | |
Not Available |
Full Name | |
---|---|
Speciality | Clinic/center |
Location | 825 Ne 10th St, Okc, Oklahoma |
Authorized Official Name and Position | Brian Maddy (CHIEF EXECUTIVE OFFICER) |
Authorized Official Contact | 4052711515 |
Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
Mailing Address | Practice Location Address |
---|---|
1122 Ne 13th St Ori236 Okc OK 73117 Ph: (405) 271-1515 | 825 Ne 10th St Oupb5200 Okc OK 73104 Ph: (405) 271-7867 |
NPI Number | 1922193374 |
---|---|
Provider Enumeration Date | 10/03/2006 |
Last Update Date | 05/12/2010 |
Identifier | Type | State | Issuer |
---|---|---|---|
1922193374 | NPI | - | NPPES |
200021910C | Medicaid | OK | |
200284910A | Medicaid | OK |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261Q00000X | Clinic/center | (* (Not Available)) | Primary |