Provider Demographics
NPI:1639636657
Name:EAST CENTRAL OKLAHOMA FAMILY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:EAST CENTRAL OKLAHOMA FAMILY HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DYER
Authorized Official - Suffix:
Authorized Official - Credentials:MSHR
Authorized Official - Phone:405-452-3151
Mailing Address - Street 1:P.O. BOX 236
Mailing Address - Street 2:
Mailing Address - City:WETUMKA
Mailing Address - State:OK
Mailing Address - Zip Code:74883
Mailing Address - Country:US
Mailing Address - Phone:405-452-3151
Mailing Address - Fax:405-452-3310
Practice Address - Street 1:1102 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:HENRYETTA
Practice Address - State:OK
Practice Address - Zip Code:74437
Practice Address - Country:US
Practice Address - Phone:918-652-9615
Practice Address - Fax:918-652-7612
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST CENTRAL OKLAHOMA FAMILY HEALT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-26
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200235450FMedicaid