Provider Demographics
NPI:1689888299
Name:DAVENPORT ADULT CARE CLINIC
Entity Type:Organization
Organization Name:DAVENPORT ADULT CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:C
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:918-423-3400
Mailing Address - Street 1:1609 N. STRONG BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-1146
Mailing Address - Country:US
Mailing Address - Phone:918-423-3400
Mailing Address - Fax:918-420-5051
Practice Address - Street 1:1609 N. STRONG BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-1146
Practice Address - Country:US
Practice Address - Phone:918-423-3400
Practice Address - Fax:918-420-5051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0044227363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKQ74675Medicare UPIN