Provider Demographics
NPI:1780025858
Name:SHEPHERD'S PLACE CLINIC LLC
Entity Type:Organization
Organization Name:SHEPHERD'S PLACE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MEBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:405-414-9139
Mailing Address - Street 1:2316 NW 23RD ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-2406
Mailing Address - Country:US
Mailing Address - Phone:405-605-3395
Mailing Address - Fax:405-605-3673
Practice Address - Street 1:2316 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-2406
Practice Address - Country:US
Practice Address - Phone:405-605-3395
Practice Address - Fax:405-605-3673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17859207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty