Provider Demographics
NPI:1699953687
Name:FAMILY CLINIC OF WELEETKA
Entity type:Organization
Organization Name:FAMILY CLINIC OF WELEETKA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICIAN ASSISTANT
Authorized Official - Phone:405-786-2248
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:WELEETKA
Mailing Address - State:OK
Mailing Address - Zip Code:74880-0337
Mailing Address - Country:US
Mailing Address - Phone:405-786-2248
Mailing Address - Fax:405-786-2006
Practice Address - Street 1:315 W. 9TH
Practice Address - Street 2:
Practice Address - City:WELEETKA
Practice Address - State:OK
Practice Address - Zip Code:74880
Practice Address - Country:US
Practice Address - Phone:405-786-2248
Practice Address - Fax:405-786-2006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK373819261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100743630BMedicaid
OK373819Medicare Oscar/Certification