=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902613490
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENERATION COMMUNITY IMPACT FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2024
-----------------------------------------------------
Last Update Date | 12/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6520 E RENO AVE STE D
-----------------------------------------------------
City | MIDWEST CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73110-2119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-455-3008
-----------------------------------------------------
Fax | 405-393-6329
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 52
-----------------------------------------------------
City | SPENCER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73084-0052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-455-3008
-----------------------------------------------------
Fax | 405-393-6329
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ANATAYA RUCKER
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 405-314-4451
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------