Provider Demographics
NPI:1093047607
Name:FACTORY, FRED NOLAN (MED)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:NOLAN
Last Name:FACTORY
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 NE 50TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73111-6604
Mailing Address - Country:US
Mailing Address - Phone:405-427-8002
Mailing Address - Fax:
Practice Address - Street 1:1416 NE 50TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73111-6604
Practice Address - Country:US
Practice Address - Phone:405-427-8002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-06
Last Update Date:2010-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health