Basic Information
| Provider Information | |||||||||
| NPI: | 1356011886 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL OKLAHOMA FAMILY MEDICAL CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 527 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | KONAWA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748491415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809253286 | ||||||||
| FaxNumber: | 5809252362 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 N MONTE VISTA ST | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748204607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804365111 | ||||||||
| FaxNumber: | 5802791994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2021 | ||||||||
| LastUpdateDate: | 09/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | WARE | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5809253286 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.