Provider Demographics
NPI:1477090652
Name:INTEGRIS AMBULATORY CARE CORPORATION
Entity Type:Organization
Organization Name:INTEGRIS AMBULATORY CARE CORPORATION
Other - Org Name:INTEGRIS JIM THORPE OUTPATIENT REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:C
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-949-3011
Mailing Address - Street 1:2203 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-5329
Mailing Address - Country:US
Mailing Address - Phone:918-786-3797
Mailing Address - Fax:918-786-7395
Practice Address - Street 1:2203 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-5329
Practice Address - Country:US
Practice Address - Phone:918-786-3797
Practice Address - Fax:918-786-7395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100736700AMedicaid
OK376538Medicare Oscar/Certification