Healthcare Provider Details

I. General information

NPI: 1902426489
Provider Name (Legal Business Name): BATTLES BROKEN BOW FAMILY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2020
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W 1ST ST
BROKEN BOW OK
74728-3901
US

IV. Provider business mailing address

115 W 1ST ST
BROKEN BOW OK
74728-3901
US

V. Phone/Fax

Practice location:
  • Phone: 580-584-5551
  • Fax: 877-697-8948
Mailing address:
  • Phone: 580-584-5551
  • Fax: 580-584-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAUREN DAWN RAGLAND
Title or Position: OFFICE MANAGER
Credential:
Phone: 580-584-5551