Basic Information
| Provider Information | |||||||||
| NPI: | 1689985343 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IDABEL CHILDREN'S CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1307 LYNN LN | ||||||||
| Address2: | |||||||||
| City: | IDABEL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747456845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802865437 | ||||||||
| FaxNumber: | 5802863955 | ||||||||
| Practice Location | |||||||||
| Address1: | 1307 LYNN LN | ||||||||
| Address2: | |||||||||
| City: | IDABEL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747456845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802865437 | ||||||||
| FaxNumber: | 5802863955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2010 | ||||||||
| LastUpdateDate: | 07/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | LEBOEUF | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | DELLINO | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5802122697 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 22507 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 100187600B | 05 | OK | MEDICAID |