Basic Information
| Provider Information | |||||||||
| NPI: | 1124661624 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HCC OF SHATTUCK, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7725 W RENO AVE STE 150 | ||||||||
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| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731279712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009623303 | ||||||||
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| Practice Location | |||||||||
| Address1: | 905 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SHATTUCK | ||||||||
| State: | OK | ||||||||
| PostalCode: | 738589205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809382551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2019 | ||||||||
| LastUpdateDate: | 10/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | BOLAR | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9729343200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.