Provider Demographics
NPI:1720480080
Name:EAST LAWTON NEIGHBORHOOD FAMILY CLINIC, PLLC
Entity type:Organization
Organization Name:EAST LAWTON NEIGHBORHOOD FAMILY CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:RUSSEL
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:SR
Authorized Official - Credentials:PA-C
Authorized Official - Phone:580-280-4644
Mailing Address - Street 1:1102 SE 36TH ST
Mailing Address - Street 2:STE. B
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-8462
Mailing Address - Country:US
Mailing Address - Phone:580-280-4644
Mailing Address - Fax:580-280-4646
Practice Address - Street 1:1102 SE 36TH ST
Practice Address - Street 2:STE. B
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-8462
Practice Address - Country:US
Practice Address - Phone:580-280-4644
Practice Address - Fax:580-280-4646
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST LAWTON NEIGHBORHOOD FAMILY CLINIC, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA674261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care