Provider Demographics
NPI:1215336193
Name:SEMINOLE CLINIC PLLC
Entity type:Organization
Organization Name:SEMINOLE CLINIC PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:KEMP
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:405-382-4939
Mailing Address - Street 1:2403 W WRANGLER BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:SEMINOLE
Mailing Address - State:OK
Mailing Address - Zip Code:74868-1900
Mailing Address - Country:US
Mailing Address - Phone:405-382-4939
Mailing Address - Fax:405-382-4947
Practice Address - Street 1:2403 W WRANGLER BLVD
Practice Address - Street 2:STE A
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868-1900
Practice Address - Country:US
Practice Address - Phone:405-382-4939
Practice Address - Fax:405-382-4947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2875261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care