Provider Demographics
NPI:1295778074
Name:FAMILY MEDICAL CLINIC
Entity type:Organization
Organization Name:FAMILY MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-326-6111
Mailing Address - Street 1:1405 E KIRK ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743-3603
Mailing Address - Country:US
Mailing Address - Phone:580-326-6111
Mailing Address - Fax:580-326-0469
Practice Address - Street 1:1405 E KIRK ST
Practice Address - Street 2:SUITE B
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-3603
Practice Address - Country:US
Practice Address - Phone:580-326-6111
Practice Address - Fax:580-326-0469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100708320AMedicaid
OK100708320AMedicaid