Healthcare Provider Details

I. General information

NPI: 1255922811
Provider Name (Legal Business Name): SUNNYLANE MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3916 S SUNNYLANE RD
DEL CITY OK
73115-3656
US

IV. Provider business mailing address

3916 S SUNNYLANE RD
DEL CITY OK
73115-3656
US

V. Phone/Fax

Practice location:
  • Phone: 405-455-5330
  • Fax:
Mailing address:
  • Phone: 405-455-5330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRADEN PETERSON
Title or Position: OWNER
Credential: NP
Phone: 405-455-5330