Healthcare Provider Details

I. General information

NPI: 1063058840
Provider Name (Legal Business Name): COUNTRY CARE FAMILY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 12/30/2019
Certification Date: 12/30/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 W 2ND ST
WELLSTON OK
74881-9496
US

IV. Provider business mailing address

PO BOX 5862
EDMOND OK
73083-5862
US

V. Phone/Fax

Practice location:
  • Phone: 405-473-7053
  • Fax: 405-832-1144
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SHERRY DIANN MITCHELL
Title or Position: OWNER
Credential: APRN-CNP
Phone: 405-532-1943