Provider Demographics
NPI:1023039187
Name:INTEGRIS AMBULATORY CARE CORPORATION
Entity Type:Organization
Organization Name:INTEGRIS AMBULATORY CARE CORPORATION
Other - Org Name:INTEGRIS JIM THORPE OP REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:C
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-949-6066
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:100
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2111 RIVERWALK DR
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2700
Practice Address - Country:US
Practice Address - Phone:405-793-7885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100736700AMedicaid
OK100736700AMedicaid