Full Name | |
---|---|
Speciality | Clinic/center |
Location | 420 Sw 10, 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 13 Ori236 Okc OK 73117 Ph: (405) 271-1515 | 420 Sw 10 Okc OK 73160 Ph: (405) 232-4160 |
NPI Number | 1497840904 |
---|---|
Provider Enumeration Date | 10/03/2006 |
Last Update Date | 05/12/2010 |
Identifier | Type | State | Issuer |
---|---|---|---|
1497840904 | NPI | - | NPPES |
100744720X | Medicaid | OK | |
200284890A | Medicaid | OK |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261Q00000X | Clinic/center | (* (Not Available)) | Primary |