Provider Demographics
NPI:1124531736
Name:PACK FAMILY CLINIC, PLLC
Entity type:Organization
Organization Name:PACK FAMILY CLINIC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FAMILY PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-728-4942
Mailing Address - Street 1:1509 AUGUSTA DR
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-8576
Mailing Address - Country:US
Mailing Address - Phone:918-728-4942
Mailing Address - Fax:918-770-8456
Practice Address - Street 1:1509 AUGUSTA DR
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-8576
Practice Address - Country:US
Practice Address - Phone:918-728-4942
Practice Address - Fax:918-770-8456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-06
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5857207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200654670AMedicaid