Healthcare Provider Details

I. General information

NPI: 1700667623
Provider Name (Legal Business Name): CHILDRENS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2023
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 CHANDLER RD STE 101
MUSKOGEE OK
74403-4955
US

IV. Provider business mailing address

3101 CHANDLER RD STE 101
MUSKOGEE OK
74403-4955
US

V. Phone/Fax

Practice location:
  • Phone: 918-687-4411
  • Fax: 918-687-4448
Mailing address:
  • Phone: 918-687-4411
  • Fax: 918-687-4448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JERRY DAVID WHATLEY
Title or Position: OWNER
Credential: MD
Phone: 918-687-4411