Provider Demographics
NPI:1497186357
Name:CARPENTER CLINIC PLLC
Entity Type:Organization
Organization Name:CARPENTER CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JO ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-332-4418
Mailing Address - Street 1:201 N MONTE VISTA ST STE A
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-7220
Mailing Address - Country:US
Mailing Address - Phone:580-332-4418
Mailing Address - Fax:580-332-0324
Practice Address - Street 1:201 N MONTE VISTA ST
Practice Address - Street 2:STE A
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-7213
Practice Address - Country:US
Practice Address - Phone:580-332-4418
Practice Address - Fax:580-332-0324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-03
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11778207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty