Provider Demographics
NPI:1366954661
Name:BLACK OAK CLINIC LLC
Entity type:Organization
Organization Name:BLACK OAK CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:APRN C-NP
Authorized Official - Phone:580-584-3099
Mailing Address - Street 1:110 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-3902
Mailing Address - Country:US
Mailing Address - Phone:405-628-8901
Mailing Address - Fax:
Practice Address - Street 1:110 W 1ST ST
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728
Practice Address - Country:US
Practice Address - Phone:580-584-3099
Practice Address - Fax:580-584-3097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-26
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200740450AMedicaid