Provider Demographics
NPI:1427722370
Name:LIFE PSYCHIATRIC CLINIC PLLC
Entity type:Organization
Organization Name:LIFE PSYCHIATRIC CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MEBIN
Authorized Official - Middle Name:BABU
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:405-414-9139
Mailing Address - Street 1:609 S KELLY AVE STE B2
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-5725
Mailing Address - Country:US
Mailing Address - Phone:405-724-6871
Mailing Address - Fax:405-726-0423
Practice Address - Street 1:609 S KELLY AVE STE B2
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-5725
Practice Address - Country:US
Practice Address - Phone:405-724-6871
Practice Address - Fax:405-726-0423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-04
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK201012720AMedicaid