Basic Information
| Provider Information | |||||||||
| NPI: | 1982267910 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY HEALTH CENTER OF SOUTHERN OKLAHOMA INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 E 24TH ST | ||||||||
| Address2: | |||||||||
| City: | TISHOMINGO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734603245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803712343 | ||||||||
| FaxNumber: | 5803713614 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734396562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805647885 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2019 | ||||||||
| LastUpdateDate: | 04/16/2019 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
| AuthorizedOfficialMiddleName: | JAREE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5803712343 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILY HEALTH CENTER OF SOUTHERN OKLAHOMA INC | ||||||||
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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.