Healthcare Provider Details

I. General information

NPI: 1700989472
Provider Name (Legal Business Name): SUNNYLANE FAMILY MEDICAL CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3916 S SUNNYLANE RD 3916 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: 405-677-3378
  • Fax: 405-677-3950
Mailing address:
  • Phone: 405-677-3378
  • Fax: 405-677-3950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1522
License Number StateOK

VIII. Authorized Official

Name: THOMAS J CARLILE
Title or Position: DR.
Credential: D.O.
Phone: 405-677-3378