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General NPI Number Information
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NPI Number | 1124531736
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Entity Type | Organization
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Legal Business Name | PACK FAMILY CLINIC, PLLC
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Dates
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Enumeration Date | 11/06/2017
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Last Update Date | 08/23/2021
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Provider Practice Location Address
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Address Line | 1509 AUGUSTA DR
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City | ADA
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State | OK
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Zip | 74820-8576
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Country | US
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Telephone | 918-728-4942
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Fax | 918-770-8456
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Provider Business Mailing Address
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Address Line | 1509 AUGUSTA DR
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City | ADA
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State | OK
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Zip | 74820-8576
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Country | US
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Telephone | 918-728-4942
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Fax | 918-770-8456
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Authorized Official
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Title or Position | FAMILY PHYSICIAN
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Name | DR. VALERIE M PACK
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Credential | DO
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Telephone | 918-728-4942
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 5857
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License Number State | OK
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