Provider Demographics
NPI:1972544807
Name:GREEN COUNTRY FAMILY CLINIC LLC
Entity Type:Organization
Organization Name:GREEN COUNTRY FAMILY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GUS
Authorized Official - Middle Name:D
Authorized Official - Last Name:CANADAY
Authorized Official - Suffix:JR
Authorized Official - Credentials:ARNP
Authorized Official - Phone:918-437-2500
Mailing Address - Street 1:1312 S GARNETT RD
Mailing Address - Street 2:STE. E
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74128-1835
Mailing Address - Country:US
Mailing Address - Phone:918-437-2500
Mailing Address - Fax:918-437-2535
Practice Address - Street 1:1312 S GARNETT RD
Practice Address - Street 2:STE E
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128-1835
Practice Address - Country:US
Practice Address - Phone:918-437-2500
Practice Address - Fax:918-437-2535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0067546363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========OtherTIN