Provider Demographics
NPI:1720633571
Name:CHILDREN'S CLINIC, PLLC
Entity Type:Organization
Organization Name:CHILDREN'S CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-687-4411
Mailing Address - Street 1:3101 CHANDLER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-4955
Mailing Address - Country:US
Mailing Address - Phone:918-687-4411
Mailing Address - Fax:918-687-4448
Practice Address - Street 1:3101 CHANDLER RD STE 101
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-4955
Practice Address - Country:US
Practice Address - Phone:918-687-4411
Practice Address - Fax:918-687-4448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty