Healthcare Provider Details

I. General information

NPI: 1992995666
Provider Name (Legal Business Name): ABC MEDICAL CLINIC, INC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 S VIRGINIA AVE
ATOKA OK
74525-3246
US

IV. Provider business mailing address

PO BOX 568
ATOKA OK
74525-0568
US

V. Phone/Fax

Practice location:
  • Phone: 580-889-3355
  • Fax: 580-927-9941
Mailing address:
  • Phone: 580-889-3355
  • Fax: 580-889-5272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2096
License Number StateOK

VIII. Authorized Official

Name: MS. LINDA L HEINZE
Title or Position: OFFICE MANAGER
Credential:
Phone: 580-889-3355