Healthcare Provider Details

I. General information

NPI: 1811295108
Provider Name (Legal Business Name): LAKESIDE WOMEN'S CENTER OF OKLAHOMA CITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11200 N PORTLAND AVE
OKLAHOMA CITY OK
73120-5045
US

IV. Provider business mailing address

PO BOX 8387
BELFAST ME
04915-8300
US

V. Phone/Fax

Practice location:
  • Phone: 405-936-1500
  • Fax: 405-418-0524
Mailing address:
  • Phone: 405-936-1577
  • Fax: 866-354-4053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DARLA MCCALLISTER
Title or Position: CFO
Credential:
Phone: 405-936-1554