Provider Demographics
NPI:1790141935
Name:INTEGRIS AMBULATORY CARE CORP
Entity Type:Organization
Organization Name:INTEGRIS AMBULATORY CARE CORP
Other - Org Name:PACER FITNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:C
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-949-3177
Mailing Address - Street 1:5520 N INDEPENDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5641
Mailing Address - Country:US
Mailing Address - Phone:405-949-3891
Mailing Address - Fax:405-949-3475
Practice Address - Street 1:5520 N INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-5641
Practice Address - Country:US
Practice Address - Phone:405-949-3891
Practice Address - Fax:405-949-3475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2297261QC1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK376538Medicare Oscar/Certification