Provider Demographics
NPI:1790371888
Name:SUNNYLANE MEDICAL CLINIC
Entity Type:Organization
Organization Name:SUNNYLANE MEDICAL CLINIC
Other - Org Name:SUNNYLANE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NOHEMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-682-8383
Mailing Address - Street 1:3916 S SUNNYLANE RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-3656
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3916 S SUNNYLANE RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-3656
Practice Address - Country:US
Practice Address - Phone:405-677-3378
Practice Address - Fax:405-930-3941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-14
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty