Provider Demographics
NPI:1528545472
Name:RESTORE FAMILY MEDICAL CLINIC
Entity Type:Organization
Organization Name:RESTORE FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNEER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:DRAPER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:580-982-6044
Mailing Address - Street 1:416020 E 1951 RD
Mailing Address - Street 2:
Mailing Address - City:ANTLERS
Mailing Address - State:OK
Mailing Address - Zip Code:74523
Mailing Address - Country:US
Mailing Address - Phone:580-982-6044
Mailing Address - Fax:
Practice Address - Street 1:416020 E 1951 RD
Practice Address - Street 2:
Practice Address - City:ANTLERS
Practice Address - State:OK
Practice Address - Zip Code:74523
Practice Address - Country:US
Practice Address - Phone:580-982-6044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK55841261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care