Provider Demographics
NPI:1184633786
Name:KIAMICHI FAMILY MEDICAL CENTER INC.
Entity Type:Organization
Organization Name:KIAMICHI FAMILY MEDICAL CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GILBREATH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-241-5294
Mailing Address - Street 1:601 SE WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-3319
Mailing Address - Country:US
Mailing Address - Phone:580-286-6688
Mailing Address - Fax:580-286-6699
Practice Address - Street 1:601 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-3319
Practice Address - Country:US
Practice Address - Phone:580-286-6688
Practice Address - Fax:580-286-6699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200003420CMedicaid
OK800522170Medicare PIN
OK200003420CMedicaid