Basic Information
| Provider Information | |||||||||
| NPI: | 1407409642 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEAM CLINICS AH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3112 COOKE WAY | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731792401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055464130 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 N 13TH ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736011831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055464130 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2019 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | NUTT | ||||||||
| AuthorizedOfficialFirstName: | TREVOR | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4055464130 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 200782030 | 05 | OK | MEDICAID |