Basic Information
| Provider Information | |||||||||
| NPI: | 1063790202 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAGLE COMMUNITY CLINIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5995 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730705995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053606764 | ||||||||
| FaxNumber: | 4053606769 | ||||||||
| Practice Location | |||||||||
| Address1: | 13800 BENSON RD | ||||||||
| Address2: | 202 | ||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730136422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054183077 | ||||||||
| FaxNumber: | 4054183076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2011 | ||||||||
| LastUpdateDate: | 07/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | PENICK | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 4053606764 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OKLAHOMA SPORTS AND ORTHOPEDICS INSTITUTE PLLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.