Healthcare Provider Details

I. General information

NPI: 1710311154
Provider Name (Legal Business Name): ACADIA FAMILY MEDICAL CLINIC L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2013
Last Update Date: 05/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 E 5TH ST
PAWHUSKA OK
74056-5204
US

IV. Provider business mailing address

230 E 5TH ST
PAWHUSKA OK
74056-5204
US

V. Phone/Fax

Practice location:
  • Phone: 918-287-9112
  • Fax: 918-287-9113
Mailing address:
  • Phone: 918-287-9112
  • Fax: 918-287-9113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27629
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number27629
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number3512416926
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number70154
License Number StateOK

VIII. Authorized Official

Name: THERESA A FLOWERETTE
Title or Position: OWNER/PROVIDER
Credential: ARNP, NP-C
Phone: 918-287-9112