Healthcare Provider Details

I. General information

NPI: 1144997693
Provider Name (Legal Business Name): CENTRAL OKLAHOMA FAMILY MEDICAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 08/24/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 ARLINGTON ST
ADA OK
74820-2928
US

IV. Provider business mailing address

527 W 3RD ST
KONAWA OK
74849-1415
US

V. Phone/Fax

Practice location:
  • Phone: 580-436-5111
  • Fax: 580-436-1159
Mailing address:
  • Phone: 580-925-3286
  • Fax: 580-925-2362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: BRENDA WARE
Title or Position: CEO
Credential:
Phone: 580-925-3286