Provider Demographics
NPI:1902613490
Name:GENERATION COMMUNITY IMPACT FOUNDATION
Entity type:Organization
Organization Name:GENERATION COMMUNITY IMPACT FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANATAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:405-314-4451
Mailing Address - Street 1:PO BOX 52
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:OK
Mailing Address - Zip Code:73084-0052
Mailing Address - Country:US
Mailing Address - Phone:405-455-3008
Mailing Address - Fax:405-393-6329
Practice Address - Street 1:6520 E RENO AVE STE D
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-2119
Practice Address - Country:US
Practice Address - Phone:405-455-3008
Practice Address - Fax:405-393-6329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-17
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center