=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316529803
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOOD SHEPHERD COMMUNITY CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2021
-----------------------------------------------------
Last Update Date | 04/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1104 WALNUT DR W
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-226-0543
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 12TH AVE NW
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401-5722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-826-3575
-----------------------------------------------------
Fax | 580-223-5113
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | TERESA MYERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 580-223-3411
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------