Basic Information
| Provider Information | |||||||||
| NPI: | 1497872717 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY CARE CENTERS OF OKLAHOMA, LLC | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAMILY CARE CENTER OF FAIRLAND, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 72250 | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784722250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618529521 | ||||||||
| FaxNumber: | 3618551454 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 E CONNER | ||||||||
| Address2: | |||||||||
| City: | FAIRLAND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186763685 | ||||||||
| FaxNumber: | 9186763008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 04/22/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FOLMAR | ||||||||
| AuthorizedOfficialFirstName: | SHARIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3618529521 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LNFA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH5803-5803 | OK | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 313M00000X | NH5803-5803 | OK | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 37E258 | 05 | OK | MEDICAID | 37-5515 | 01 | MEDICARE CCN | OTHER |