Provider Demographics
NPI:1215353016
Name:FULL LIFE FAMILY RESOURCE CENTER LLC
Entity type:Organization
Organization Name:FULL LIFE FAMILY RESOURCE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLYNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:580-584-2478
Mailing Address - Street 1:205 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-3975
Mailing Address - Country:US
Mailing Address - Phone:580-584-2478
Mailing Address - Fax:580-584-2478
Practice Address - Street 1:205 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728-3975
Practice Address - Country:US
Practice Address - Phone:580-584-2478
Practice Address - Fax:580-584-2478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3881251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK447-76-2689Medicaid