Provider Demographics
NPI:1598140212
Name:FAMILY HEALTH CENTER OF SOUTHERN OKLAHOMA INC
Entity type:Organization
Organization Name:FAMILY HEALTH CENTER OF SOUTHERN OKLAHOMA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-387-0509
Mailing Address - Street 1:610 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-3245
Mailing Address - Country:US
Mailing Address - Phone:580-371-2343
Mailing Address - Fax:580-371-3614
Practice Address - Street 1:610 E 24TH ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-3245
Practice Address - Country:US
Practice Address - Phone:580-371-2343
Practice Address - Fax:580-371-3614
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY HEALTH CENTER OF SOUTHERN OKLAHOMA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-23
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200018910EMedicaid