MEDICARE: EDWIN FAIR COMMUNITY MENTAL HEALTH CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043382484
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDWIN FAIR COMMUNITY MENTAL HEALTH CENTER, INC.

Provider Business Mailing Address
First Line	:	1500 N 5TH ST
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-2758
Country	:	US
Telephone Number	:	580-762-7561
Fax Number	:	580-762-2576

Provider Business Practice Location Address
First Line	:	1500 N 5TH ST
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-2758
Country	:	US
Telephone Number	:	580-762-7561
Fax Number	:	580-762-2576

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. MISTY D DANIELS
Credential	:	MA
Telephone Number	:	580-762-7561

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	06/28/2011

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