Basic Information
| Provider Information | |||||||||
| NPI: | 1700956240 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CANADIAN VALLEY CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 PARKVIEW DR | ||||||||
| Address2: | |||||||||
| City: | EL RENO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730362107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052622114 | ||||||||
| FaxNumber: | 4052622306 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 PARKVIEW DR | ||||||||
| Address2: | |||||||||
| City: | EL RENO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730362107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052622114 | ||||||||
| FaxNumber: | 4052622306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 06/27/2011 | ||||||||
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| AuthorizedOfficialLastName: | WALDE | ||||||||
| AuthorizedOfficialFirstName: | DIANNE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4052622114 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 100729100A | 05 | OK | MEDICAID |