Provider Demographics
NPI:1902269012
Name:KIAMICHI FAMILY MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:KIAMICHI FAMILY MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GILBREATH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-241-5294
Mailing Address - Street 1:6026 BATTIEST PICKENS RD
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-5033
Mailing Address - Country:US
Mailing Address - Phone:580-241-5294
Mailing Address - Fax:580-241-5739
Practice Address - Street 1:204 E. JACKSON
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-3821
Practice Address - Country:US
Practice Address - Phone:580-326-9555
Practice Address - Fax:580-241-5739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)