Provider Demographics
NPI:1982896544
Name:DYCUS-CAMP CLINIC INC
Entity type:Organization
Organization Name:DYCUS-CAMP CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-794-4474
Mailing Address - Street 1:320 N SERVICE RD
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-4945
Mailing Address - Country:US
Mailing Address - Phone:405-794-4474
Mailing Address - Fax:
Practice Address - Street 1:320 N SERVICE RD
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-4945
Practice Address - Country:US
Practice Address - Phone:405-794-4474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKCP8463Medicare PIN