MEDICARE: CENTRAL OKLAHOMA FAMILY MEDICAL 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	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1144997693
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL OKLAHOMA FAMILY MEDICAL CENTER, INC

Provider Business Mailing Address
First Line	:	527 W 3RD ST
Second Line	:
City	:	KONAWA
State	:	OK
Zip	:	74849-1415
Country	:	US
Telephone Number	:	580-925-3286
Fax Number	:	580-925-2362

Provider Business Practice Location Address
First Line	:	2901 ARLINGTON ST
Second Line	:
City	:	ADA
State	:	OK
Zip	:	74820-2928
Country	:	US
Telephone Number	:	580-436-5111
Fax Number	:	580-436-1159

Authorized Official
Title or Position	:	CEO
Name	:	BRENDA WARE
Credential	:
Telephone Number	:	580-925-3286

Provider Enumeration Date	:	08/24/2021
Last Update Date	:	08/24/2021

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