Healthcare Provider Details

I. General information

NPI: 1720633571
Provider Name (Legal Business Name): CHILDREN'S CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2019
Last Update Date: 08/08/2019
Certification Date:
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: MR. RYAN HARDAWAY
Title or Position: GENERAL MANAGER
Credential:
Phone: 918-687-4411