Basic Information
| Provider Information | |||||||||
| NPI: | 1528417409 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VALLEY FAMILY CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 106 BURR AVE | ||||||||
| Address2: | |||||||||
| City: | PAULS VALLEY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730753848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052384633 | ||||||||
| FaxNumber: | 4052384690 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 BURR AVE | ||||||||
| Address2: | |||||||||
| City: | PAULS VALLEY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730753848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052384633 | ||||||||
| FaxNumber: | 4052384690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2016 | ||||||||
| LastUpdateDate: | 06/10/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4052384633 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | OK | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1467593210 | 01 | OK | NPI | OTHER | 1730155904 | 01 | OK | NPI | OTHER | 200162480B | 05 | OK | MEDICAID | 100131280B | 05 | OK | MEDICAID | 1972531465 | 01 | OK | NPI | OTHER | 100124310A | 05 | OK | MEDICAID |