Healthcare Provider Details

I. General information

NPI: 1053792093
Provider Name (Legal Business Name): CHILDREN'S CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
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:
Mailing address:
  • Phone: 918-687-4411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRANDI LYNN JONES
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 918-687-4411