Healthcare Provider Details

I. General information

NPI: 1578725636
Provider Name (Legal Business Name): THOMAS FAMILY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 12/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1928 S 4TH ST
CHICKASHA OK
73018-5903
US

IV. Provider business mailing address

1928 S 4TH ST
CHICKASHA OK
73018-5903
US

V. Phone/Fax

Practice location:
  • Phone: 405-224-7755
  • Fax: 405-224-7748
Mailing address:
  • Phone: 405-224-7755
  • Fax: 405-224-7748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number17600
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 467
License Number StateOK

VIII. Authorized Official

Name: MR. BRADY G AUNKO
Title or Position: ADMINISTRATOR
Credential:
Phone: 405-224-7755