Provider Demographics
NPI:1043382484
Name:EDWIN FAIR COMMUNITY MENTAL HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:EDWIN FAIR COMMUNITY MENTAL HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:D
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:580-762-7561
Mailing Address - Street 1:1500 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2758
Mailing Address - Country:US
Mailing Address - Phone:580-762-7561
Mailing Address - Fax:580-762-2576
Practice Address - Street 1:1500 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2758
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:2006-11-14
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100749540DMedicaid
OKWCDHZMedicare ID - Type UnspecifiedEFC DOC SERVICES