Healthcare Provider Details

I. General information

NPI: 1831291293
Provider Name (Legal Business Name): CENTRAL OKLAHOMA FAMILY MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 WEST 3RD ST
KONAWA OK
74849
US

IV. Provider business mailing address

527 WEST 3RD STREET
KONAWA OK
74849
US

V. Phone/Fax

Practice location:
  • Phone: 580-925-3286
  • Fax: 580-925-2362
Mailing address:
  • Phone: 580-925-3286
  • Fax: 580-925-9149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BRENDA WARE
Title or Position: CEO
Credential:
Phone: 580-925-3286