Provider Demographics
NPI:1730307422
Name:PONCA CITY ORTHOPAEDIC AND SPORTS MEDICINE CLINIC, INC
Entity Type:Organization
Organization Name:PONCA CITY ORTHOPAEDIC AND SPORTS MEDICINE CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:L
Authorized Official - Last Name:BORING
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:580-765-8240
Mailing Address - Street 1:119 PATTON DR
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2030
Mailing Address - Country:US
Mailing Address - Phone:580-765-8240
Mailing Address - Fax:
Practice Address - Street 1:119 PATTON DR
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2030
Practice Address - Country:US
Practice Address - Phone:580-765-8240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11690174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKC94704Medicare UPIN