Healthcare Provider Details

I. General information

NPI: 1306973094
Provider Name (Legal Business Name): CENTRAL OKLAHOMA FAMILY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 W 3RD ST
KONAWA OK
74849-1415
US

IV. Provider business mailing address

527 W 3RD ST
KONAWA OK
74849-1415
US

V. Phone/Fax

Practice location:
  • Phone: 580-925-3266
  • Fax: 580-925-9149
Mailing address:
  • Phone: 580-925-3266
  • Fax: 580-925-9149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number1618
License Number StateOK

VIII. Authorized Official

Name: KASEY LEE BRUNDIDGE
Title or Position: PA-C
Credential: MPA
Phone: 580-925-3266