Healthcare Provider Details

I. General information

NPI: 1154489540
Provider Name (Legal Business Name): CMS OUTPATIENT CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 08/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N MONTE VISTA ST SUITE C
ADA OK
74820-7220
US

IV. Provider business mailing address

201 N MONTE VISTA ST SUITE C
ADA OK
74820-7220
US

V. Phone/Fax

Practice location:
  • Phone: 580-310-0015
  • Fax: 580-310-0909
Mailing address:
  • Phone: 580-310-0015
  • Fax: 580-310-0909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL R, STAFFORD
Title or Position: PHYSICIAN
Credential: DO
Phone: 580-310-0015