Provider Demographics
NPI:1144065012
Name:CLINIC AT 410 PLLC
Entity type:Organization
Organization Name:CLINIC AT 410 PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP-BC
Authorized Official - Prefix:
Authorized Official - First Name:TRESSA
Authorized Official - Middle Name:ANTIONETTE
Authorized Official - Last Name:MATCHEN
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:580-565-9975
Mailing Address - Street 1:PO BOX 1118
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73439-1118
Mailing Address - Country:US
Mailing Address - Phone:580-565-9975
Mailing Address - Fax:888-241-2340
Practice Address - Street 1:410 HWY 70
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OK
Practice Address - Zip Code:73439
Practice Address - Country:US
Practice Address - Phone:580-565-9975
Practice Address - Fax:888-241-2340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-01
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty