Provider Demographics
NPI:1912094244
Name:SOUTH MOORE MEDICAL CLINIC, PC
Entity type:Organization
Organization Name:SOUTH MOORE MEDICAL CLINIC, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:R
Authorized Official - Last Name:LAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:405-912-4900
Mailing Address - Street 1:14800 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-7112
Mailing Address - Country:US
Mailing Address - Phone:405-912-4900
Mailing Address - Fax:405-912-4903
Practice Address - Street 1:14800 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73170-7112
Practice Address - Country:US
Practice Address - Phone:405-912-4900
Practice Address - Fax:405-912-4903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK560202001OtherDME NUMBER