Provider Demographics
NPI:1770115933
Name:COUNTRY CARE CLINIC
Entity type:Organization
Organization Name:COUNTRY CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-356-3001
Mailing Address - Street 1:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OK
Mailing Address - Zip Code:74881-0304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 W 2ND ST STE B
Practice Address - Street 2:
Practice Address - City:WELLSTON
Practice Address - State:OK
Practice Address - Zip Code:74881-9496
Practice Address - Country:US
Practice Address - Phone:405-356-3001
Practice Address - Fax:405-832-1144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care