Basic Information
| Provider Information | |||||||||
| NPI: | 1831291293 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL OKLAHOMA FAMILY MEDICAL CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTRAL OKLAHOMA FAMILY MED CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 527 WEST 3RD STREET | ||||||||
| Address2: | |||||||||
| City: | KONAWA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809253286 | ||||||||
| FaxNumber: | 5809259149 | ||||||||
| Practice Location | |||||||||
| Address1: | 527 WEST 3RD ST | ||||||||
| Address2: | |||||||||
| City: | KONAWA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809253286 | ||||||||
| FaxNumber: | 5809252362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 01/31/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WARE | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5809253286 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 100737160D | 05 | OK | MEDICAID |