Healthcare Provider Details

I. General information

NPI: 1568407476
Provider Name (Legal Business Name): CHANDLER OUTREACH MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 MANVEL AVE STE C
CHANDLER OK
74834-4438
US

IV. Provider business mailing address

PO BOX 108810
OKLAHOMA CITY OK
73101-8810
US

V. Phone/Fax

Practice location:
  • Phone: 405-258-5252
  • Fax: 405-258-5552
Mailing address:
  • Phone: 405-608-3800
  • Fax: 405-608-3838

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: KRISTIN SELLS
Title or Position: DIRECTOR
Credential: P.A.
Phone: 405-258-5252