Provider Demographics
NPI:1407863053
Name:ARDMORE FAMILY HEALTH CARE, PLLC
Entity Type:Organization
Organization Name:ARDMORE FAMILY HEALTH CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-223-1313
Mailing Address - Street 1:812 12TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-5708
Mailing Address - Country:US
Mailing Address - Phone:580-223-1313
Mailing Address - Fax:580-223-1629
Practice Address - Street 1:812 12TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-5708
Practice Address - Country:US
Practice Address - Phone:580-223-1313
Practice Address - Fax:580-223-1629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21765207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========OtherTAX ID