Basic Information
| Provider Information | |||||||||
| NPI: | 1215336193 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SEMINOLE CLINIC PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SEMINOLE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2403 W WRANGLER BLVD | ||||||||
| Address2: | STE A | ||||||||
| City: | SEMINOLE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748681900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053824939 | ||||||||
| FaxNumber: | 4053824947 | ||||||||
| Practice Location | |||||||||
| Address1: | 2403 W WRANGLER BLVD | ||||||||
| Address2: | STE A | ||||||||
| City: | SEMINOLE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748681900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053824939 | ||||||||
| FaxNumber: | 4053824947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2014 | ||||||||
| LastUpdateDate: | 08/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | KEMP | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | LEON | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4053824939 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 2875 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.