Provider Demographics
NPI:1972764736
Name:EDWIN FAIR CMHC
Entity type:Organization
Organization Name:EDWIN FAIR CMHC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:580-762-7561
Mailing Address - Street 1:1500 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2827
Mailing Address - Country:US
Mailing Address - Phone:580-762-7561
Mailing Address - Fax:580-762-2576
Practice Address - Street 1:201 E CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-4311
Practice Address - Country:US
Practice Address - Phone:580-762-7561
Practice Address - Fax:580-762-2576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100749540EMedicaid
OK100749540TMedicaid
OK100749540XMedicaid