Provider Demographics
NPI:1285765727
Name:MINUTECLINIC DIAGNOSTIC OF OKLAHOMA LLC
Entity type:Organization
Organization Name:MINUTECLINIC DIAGNOSTIC OF OKLAHOMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:PINCINCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-770-3813
Mailing Address - Street 1:PO BOX 772
Mailing Address - Street 2:MINUTECLINIC CREDENTIALING-MC2295
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-0784
Mailing Address - Country:US
Mailing Address - Phone:401-770-1768
Mailing Address - Fax:401-652-9787
Practice Address - Street 1:1520 S BRYANT AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-6028
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:401-652-9787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKDO1961OtherMEDICARE RAILROAD
OKOKB5013Medicare PIN