Healthcare Provider Details

I. General information

NPI: 1386812345
Provider Name (Legal Business Name): SPECTRA FAMILY MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6520 E RENO SUITE A
MIDWEST CITY OK
73110-2109
US

IV. Provider business mailing address

PO BOX 223
SPENCER OK
73084-0223
US

V. Phone/Fax

Practice location:
  • Phone: 405-733-0120
  • Fax: 405-733-7876
Mailing address:
  • Phone: 405-733-0120
  • Fax: 405-733-7876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number8459
License Number StateOK

VIII. Authorized Official

Name: MRS. DAVONDRA LOVE OWENS
Title or Position: CFO
Credential:
Phone: 405-733-0120