Healthcare Provider Details

I. General information

NPI: 1922571009
Provider Name (Legal Business Name): CENTRAL OKLAHOMA FAMILY MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 08/08/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 N MONTE VISTA STREET
ADA OK
74820
US

IV. Provider business mailing address

304 N MONTE VISTA
ADA OK
74820
US

V. Phone/Fax

Practice location:
  • Phone: 580-436-5111
  • Fax:
Mailing address:
  • Phone: 580-436-5111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
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