Healthcare Provider Details

I. General information

NPI: 1558733782
Provider Name (Legal Business Name): EASTPOINTE MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2015
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 S BROADWAY ST
POTEAU OK
74953-2900
US

IV. Provider business mailing address

1506 S BROADWAY ST
POTEAU OK
74953-2900
US

V. Phone/Fax

Practice location:
  • Phone: 903-495-1105
  • Fax:
Mailing address:
  • Phone: 918-647-7046
  • Fax: 918-647-7047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MISS ROXANN SHAW
Title or Position: PRESIDENT
Credential:
Phone: 903-495-1105