Provider Demographics
NPI:1720290539
Name:CENTRAL OK FAMILY MED CTR
Entity Type:Organization
Organization Name:CENTRAL OK FAMILY MED CTR
Other - Org Name:COFMC PRAGUE
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:H
Authorized Official - Last Name:ANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-925-8819
Mailing Address - Street 1:PO BOX 358
Mailing Address - Street 2:527 W 3RD ST
Mailing Address - City:KONAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74849
Mailing Address - Country:US
Mailing Address - Phone:580-925-3286
Mailing Address - Fax:580-925-2362
Practice Address - Street 1:RT 1 BOX 85A
Practice Address - Street 2:
Practice Address - City:PRAGUE
Practice Address - State:OK
Practice Address - Zip Code:74864
Practice Address - Country:US
Practice Address - Phone:405-567-0054
Practice Address - Fax:405-567-0087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========Medicare ID - Type Unspecified