Provider Demographics
NPI:1801840368
Name:THE FAMILY CARE CENTER OF HARRAH, INC.
Entity Type:Organization
Organization Name:THE FAMILY CARE CENTER OF HARRAH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LEN
Authorized Official - Middle Name:U
Authorized Official - Last Name:LACEFIELD
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:405-454-2404
Mailing Address - Street 1:PO BOX 900
Mailing Address - Street 2:
Mailing Address - City:HARRAH
Mailing Address - State:OK
Mailing Address - Zip Code:73045-0900
Mailing Address - Country:US
Mailing Address - Phone:405-454-2404
Mailing Address - Fax:405-454-6372
Practice Address - Street 1:20826 MAIN ST
Practice Address - Street 2:
Practice Address - City:HARRAH
Practice Address - State:OK
Practice Address - Zip Code:73045-9755
Practice Address - Country:US
Practice Address - Phone:405-454-2404
Practice Address - Fax:405-454-6372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
OK2323261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK400522578Medicare PIN