Provider Demographics
NPI:1700956240
Name:CANADIAN VALLEY CLINIC INC
Entity Type:Organization
Organization Name:CANADIAN VALLEY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-262-2114
Mailing Address - Street 1:2001 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-2107
Mailing Address - Country:US
Mailing Address - Phone:405-262-2114
Mailing Address - Fax:405-262-2306
Practice Address - Street 1:2001 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-2107
Practice Address - Country:US
Practice Address - Phone:405-262-2114
Practice Address - Fax:405-262-2306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100729100AMedicaid