Provider Demographics
NPI:1689985343
Name:IDABEL CHILDREN'S CLINIC, INC.
Entity Type:Organization
Organization Name:IDABEL CHILDREN'S CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DELLINO
Authorized Official - Last Name:LEBOEUF
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:580-212-2697
Mailing Address - Street 1:1307 LYNN LN
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-6845
Mailing Address - Country:US
Mailing Address - Phone:580-286-5437
Mailing Address - Fax:580-286-3955
Practice Address - Street 1:1307 LYNN LN
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-6845
Practice Address - Country:US
Practice Address - Phone:580-286-5437
Practice Address - Fax:580-286-3955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22507261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100187600BMedicaid
OKH12755Medicare UPIN