Healthcare Provider Details

I. General information

NPI: 1598911752
Provider Name (Legal Business Name): CENTRAL OKLAHOMA FAMILY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NBU 1706 HIGHWAY 99 SOUTH
PRAGUE OK
74864
US

IV. Provider business mailing address

527 W 3RD ST
KONAWA OK
74849-1415
US

V. Phone/Fax

Practice location:
  • Phone: 580-925-3286
  • Fax: 580-925-2362
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: MR. CASEY HAROLD ANSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 580-925-3286