Provider Demographics
NPI:1447327622
Name:NOBLE FAMILY HEALTHCARE CLINIC
Entity type:Organization
Organization Name:NOBLE FAMILY HEALTHCARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:PENDARVIS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:405-872-5403
Mailing Address - Street 1:PO BOX 2096
Mailing Address - Street 2:205 S. MAIN
Mailing Address - City:NOBLE
Mailing Address - State:OK
Mailing Address - Zip Code:73068-2096
Mailing Address - Country:US
Mailing Address - Phone:405-872-5403
Mailing Address - Fax:405-872-5407
Practice Address - Street 1:205 S. MAIN
Practice Address - Street 2:
Practice Address - City:NOBLE
Practice Address - State:OK
Practice Address - Zip Code:73068-2096
Practice Address - Country:US
Practice Address - Phone:405-872-5403
Practice Address - Fax:405-872-5407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK400522556Medicare ID - Type Unspecified