Provider Demographics
NPI:1942810056
Name:LANE FAMILY CLINIC LLC
Entity Type:Organization
Organization Name:LANE FAMILY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAMI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:580-212-0303
Mailing Address - Street 1:PO BOX 650
Mailing Address - Street 2:
Mailing Address - City:WRIGHT CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74766-0650
Mailing Address - Country:US
Mailing Address - Phone:580-981-2104
Mailing Address - Fax:580-981-2105
Practice Address - Street 1:207 WEST 10TH STREET
Practice Address - Street 2:
Practice Address - City:WRIGHT CITY
Practice Address - State:OK
Practice Address - Zip Code:74766
Practice Address - Country:US
Practice Address - Phone:580-981-2104
Practice Address - Fax:580-981-2105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty