Provider Demographics
NPI:1033754502
Name:EXPRESS FAMILY CARE NORTHWEST
Entity Type:Organization
Organization Name:EXPRESS FAMILY CARE NORTHWEST
Other - Org Name:EXPRESS FAMILY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:TISDALE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:405-470-1224
Mailing Address - Street 1:7117 W WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-5575
Mailing Address - Country:US
Mailing Address - Phone:405-470-1224
Mailing Address - Fax:
Practice Address - Street 1:7117 W WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-5575
Practice Address - Country:US
Practice Address - Phone:405-470-1224
Practice Address - Fax:405-217-0063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-08
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care