Provider Demographics
NPI:1568576619
Name:FAMILY PRACTICE ASSOCIATES
Entity Type:Organization
Organization Name:FAMILY PRACTICE ASSOCIATES
Other - Org Name:FAMILY HEALTH CONVENIENT CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREL
Authorized Official - Middle Name:CARRIE
Authorized Official - Last Name:MCCULLOH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-223-6003
Mailing Address - Street 1:1306 12TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1285
Mailing Address - Country:US
Mailing Address - Phone:580-223-6003
Mailing Address - Fax:833-314-0305
Practice Address - Street 1:1306 12TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1285
Practice Address - Country:US
Practice Address - Phone:580-223-6003
Practice Address - Fax:833-314-0305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK700522043Medicare PIN