Provider Demographics
NPI:1992892228
Name:CHANDLER OUTREACH MEDICAL CENTER, LLC
Entity type:Organization
Organization Name:CHANDLER OUTREACH MEDICAL CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLS
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:405-258-5252
Mailing Address - Street 1:PO BOX 108810
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73101-8810
Mailing Address - Country:US
Mailing Address - Phone:405-608-1200
Mailing Address - Fax:405-608-1250
Practice Address - Street 1:1206 MANVEL AVE
Practice Address - Street 2:STE C
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834-4401
Practice Address - Country:US
Practice Address - Phone:405-258-5252
Practice Address - Fax:405-258-5552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5350630001Medicare NSC