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General NPI Number Information
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NPI Number | 1275326191
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Entity Type | Organization
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Legal Business Name | MAIN STREET FAMILY CLINIC LLC
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Dates
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Enumeration Date | 05/23/2025
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Last Update Date | 07/09/2025
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Provider Practice Location Address
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Address Line | 213 W MAIN ST
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City | CANTON
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State | OK
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Zip | 73724-1234
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Country | US
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Telephone | 405-506-9101
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Fax | 405-936-0561
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Provider Business Mailing Address
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Address Line | PO BOX 57390
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City | OKLAHOMA CITY
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State | OK
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Zip | 73157-7390
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Country | US
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Telephone | 405-506-9101
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Fax | 405-936-0561
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Authorized Official
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Title or Position | OWNER
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Name | BETH HOLDERBY
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Credential | APRN
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Telephone | 580-551-9131
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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 |
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License Number State |
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