=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063927408
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLASSEN FAMILY PRACTICE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2017
-----------------------------------------------------
Last Update Date | 07/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1025 SW 4TH ST STE 101
-----------------------------------------------------
City | MOORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73160-2404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-378-2001
-----------------------------------------------------
Fax | 405-445-7660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2818 CLASSEN BLVD
-----------------------------------------------------
City | NORMAN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73071-4059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-310-3400
-----------------------------------------------------
Fax | 405-701-6158
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | HUSSEIN TORBATI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-701-7111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------