MEDICARE: FAMILY HEALTH CENTER OF SOUTHERN OKLAHOMA 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)		OK

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	:	1174830665
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY HEALTH CENTER OF SOUTHERN OKLAHOMA INC

Provider Business Mailing Address
First Line	:	610 E 24TH ST
Second Line	:
City	:	TISHOMINGO
State	:	OK
Zip	:	73460-3245
Country	:	US
Telephone Number	:	580-371-2343
Fax Number	:	580-371-3614

Provider Business Practice Location Address
First Line	:	107 E POST AVE
Second Line	:
City	:	COALGATE
State	:	OK
Zip	:	74538-3004
Country	:	US
Telephone Number	:	580-927-2828
Fax Number	:	580-258-3000

Authorized Official
Title or Position	:	CREDENTIALING OFFICER
Name	:	ASHLEY WELLS
Credential	:
Telephone Number	:	580-387-0509

Provider Enumeration Date	:	09/07/2010
Last Update Date	:	08/21/2024

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Directions to “FAMILY HEALTH CENTER OF SOUTHERN OKLAHOMA INC ” Practice Location

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