Provider Demographics
NPI:1265924872
Name:SKINNER FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:SKINNER FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TENIA
Authorized Official - Middle Name:LADONNA
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:405-641-6628
Mailing Address - Street 1:129 N 3RD AVE STE C
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-4246
Mailing Address - Country:US
Mailing Address - Phone:405-641-6628
Mailing Address - Fax:405-527-6569
Practice Address - Street 1:129 N 3RD AVE STE C
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080
Practice Address - Country:US
Practice Address - Phone:405-641-6628
Practice Address - Fax:405-527-8669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200204740AMedicaid