Provider Demographics
NPI:1053327486
Name:BASS MEMORIAL BAPTIST HOSPITAL DBA INTEGRIS BASS BAPTIST HEALTH CENTER
Entity Type:Organization
Organization Name:BASS MEMORIAL BAPTIST HOSPITAL DBA INTEGRIS BASS BAPTIST HEALTH CENTER
Other - Org Name:ADVANCE FOOD COMPANY EMPLOYEE'S MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:B
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-951-2616
Mailing Address - Street 1:PO BOX 5038
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73702-5038
Mailing Address - Country:US
Mailing Address - Phone:580-548-1367
Mailing Address - Fax:580-548-1583
Practice Address - Street 1:915 E GARRIOTT RD
Practice Address - Street 2:SUITE D
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-6156
Practice Address - Country:US
Practice Address - Phone:580-234-8998
Practice Address - Fax:580-234-8465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK37D1036503OtherCLIA