Basic Information
| Provider Information | |||||||||
| NPI: | 1467993253 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST OKLAHOMA MEDICAL CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 W OHIO AVE | ||||||||
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| City: | COALGATE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745382827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809272334 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1308 E CARL ALBERT PKWY | ||||||||
| Address2: | |||||||||
| City: | MCALESTER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745015236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809272334 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2017 | ||||||||
| LastUpdateDate: | 03/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | HELTON | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5809272334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.