Provider Demographics
NPI:1720603996
Name:TEAM CLINICS AH LLC
Entity Type:Organization
Organization Name:TEAM CLINICS AH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:
Authorized Official - Last Name:NUTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-546-4130
Mailing Address - Street 1:3112 COOKE WAY
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73179-2401
Mailing Address - Country:US
Mailing Address - Phone:405-600-6869
Mailing Address - Fax:
Practice Address - Street 1:3801 34TH ST
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801
Practice Address - Country:US
Practice Address - Phone:405-546-4130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-12
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200782030Medicaid