Provider Demographics
NPI:1942649520
Name:FIRST MED CLINIC S 104TH LLC
Entity Type:Organization
Organization Name:FIRST MED CLINIC S 104TH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:LECHTENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-471-6400
Mailing Address - Street 1:1221 N KELLY AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-4865
Mailing Address - Country:US
Mailing Address - Phone:405-471-6400
Mailing Address - Fax:
Practice Address - Street 1:1140 SW 104TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-2992
Practice Address - Country:US
Practice Address - Phone:405-691-3100
Practice Address - Fax:405-691-3106
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCE PHYSICIANS GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty