Provider Demographics
NPI:1386812345
Name:SPECTRA FAMILY MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:SPECTRA FAMILY MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAVONDRA
Authorized Official - Middle Name:LOVE
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-733-0120
Mailing Address - Street 1:PO BOX 223
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:OK
Mailing Address - Zip Code:73084-0223
Mailing Address - Country:US
Mailing Address - Phone:405-733-0120
Mailing Address - Fax:405-733-7876
Practice Address - Street 1:6520 E RENO
Practice Address - Street 2:SUITE A
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-2109
Practice Address - Country:US
Practice Address - Phone:405-733-0120
Practice Address - Fax:405-733-7876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8459173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200131340AMedicaid
OK200131340AMedicaid