Basic Information
| Provider Information | |||||||||
| NPI: | 1902404965 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VARIETY CARE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 N GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731071818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056326688 | ||||||||
| FaxNumber: | 8446899671 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 NE 50TH ST STE 117 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731051811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056326688 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2020 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | REDDOUT | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 4056326688 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VARIETY CARE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.