Healthcare Provider Details

I. General information

NPI: 1053431452
Provider Name (Legal Business Name): FAMILY CARE OF BROKEN ARROW, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 S. ELM PL. SUITE A
BROKEN ARROW OK
74012-7910
US

IV. Provider business mailing address

3100 S. ELM PL. SUITE A
BROKEN ARROW OK
74012-7910
US

V. Phone/Fax

Practice location:
  • Phone: 918-455-7777
  • Fax: 918-455-8105
Mailing address:
  • Phone: 918-455-7777
  • Fax: 918-455-8105

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. LEROY O. JESKE
Title or Position: MEDICAL DIRECTOR D.O.
Credential: D.O.
Phone: 918-455-7777