Healthcare Provider Details

I. General information

NPI: 1881892602
Provider Name (Legal Business Name): THUNDERBIRD CLUBHOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 E MAIN ST NONE
NORMAN OK
73071-5822
US

IV. Provider business mailing address

531 E MAIN ST NONE
NORMAN OK
73071-5822
US

V. Phone/Fax

Practice location:
  • Phone: 405-321-7331
  • Fax: 405-364-6058
Mailing address:
  • Phone: 405-321-7331
  • Fax: 405-364-6058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberNONE
License Number StateOK

VIII. Authorized Official

Name: PROF. PAM E. SANFORD
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 405-321-7331