Healthcare Provider Details

I. General information

NPI: 1194937904
Provider Name (Legal Business Name): CENTRAL OK FAMILY MED CTR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 10/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 72ND SE
NOBLE OK
73068
US

IV. Provider business mailing address

PO BOX 358 527 W 3RD ST
KONAWA OK
74849
US

V. Phone/Fax

Practice location:
  • Phone: 405-872-1270
  • Fax: 405-872-1269
Mailing address:
  • Phone: 580-925-3286
  • Fax: 580-925-2362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. DENISE SHARP
Title or Position: INTERIM CEO
Credential: AR,NP.
Phone: 580-925-3286