Provider Demographics
NPI:1952482192
Name:HINTON FAMILY MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:HINTON FAMILY MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:GALE
Authorized Official - Last Name:GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:405-542-6131
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:1500 N BROADWAY BVLD
Mailing Address - City:HINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73047-0220
Mailing Address - Country:US
Mailing Address - Phone:405-542-6131
Mailing Address - Fax:405-542-3665
Practice Address - Street 1:1500 N BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:HINTON
Practice Address - State:OK
Practice Address - Zip Code:73047-0220
Practice Address - Country:US
Practice Address - Phone:405-542-6131
Practice Address - Fax:405-542-3665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14812207Q00000X
OKPA 873363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200073360AMedicaid
OK200073360AMedicaid
OK900522346Medicare PIN