Provider Demographics
NPI:1518049055
Name:EL RENO FAMILY CLINIC AND MINOR EMERGENCY SERVICES, INC
Entity Type:Organization
Organization Name:EL RENO FAMILY CLINIC AND MINOR EMERGENCY SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:DICINTIO
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:405-295-2200
Mailing Address - Street 1:203 S ROCK ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-2734
Mailing Address - Country:US
Mailing Address - Phone:405-295-2200
Mailing Address - Fax:405-295-2178
Practice Address - Street 1:203 S ROCK ISLAND AVE
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-2734
Practice Address - Country:US
Practice Address - Phone:405-295-2200
Practice Address - Fax:405-295-2178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA564261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK454437244011OtherBC BS