Basic Information
| Provider Information | |||||||||
| NPI: | 1568407476 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHANDLER OUTREACH MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 108810 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731018810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056083800 | ||||||||
| FaxNumber: | 4056083838 | ||||||||
| Practice Location | |||||||||
| Address1: | 1406 MANVEL AVE | ||||||||
| Address2: | STE C | ||||||||
| City: | CHANDLER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748344438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052585252 | ||||||||
| FaxNumber: | 4052585552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SELLS | ||||||||
| AuthorizedOfficialFirstName: | KRISTIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4052585252 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | P.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.