Provider Demographics
NPI:1548609217
Name:FAIRFAX MEDICAL FACILITIES INC
Entity Type:Organization
Organization Name:FAIRFAX MEDICAL FACILITIES INC
Other - Org Name:CLEVELAND FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-642-3100
Mailing Address - Street 1:212 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:OK
Mailing Address - Zip Code:74637-3023
Mailing Address - Country:US
Mailing Address - Phone:918-642-3100
Mailing Address - Fax:918-642-5639
Practice Address - Street 1:100 N HICKERSON DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OK
Practice Address - Zip Code:74020-4003
Practice Address - Country:US
Practice Address - Phone:918-642-3515
Practice Address - Fax:918-642-3519
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRFAX MEDICAL FACILITIES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)