Provider Demographics
NPI:1558686246
Name:LATINO COMMUNITY DEVELOPMENT AGENCY
Entity Type:Organization
Organization Name:LATINO COMMUNITY DEVELOPMENT AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:B
Authorized Official - Last Name:FENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:405-236-0701
Mailing Address - Street 1:420 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-5610
Mailing Address - Country:US
Mailing Address - Phone:405-236-0701
Mailing Address - Fax:405-236-0773
Practice Address - Street 1:420 SW 10TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-5610
Practice Address - Country:US
Practice Address - Phone:405-236-0701
Practice Address - Fax:405-236-0773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200075270Medicaid