Provider Demographics
NPI:1538450689
Name:SOVEREIGN FAMILY CLINIC, LLC
Entity type:Organization
Organization Name:SOVEREIGN FAMILY CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, SOVEREIGN
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:ANOATUBBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-272-5160
Mailing Address - Street 1:1007 N COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2847
Mailing Address - Country:US
Mailing Address - Phone:580-421-8700
Mailing Address - Fax:580-421-8785
Practice Address - Street 1:1007 N COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2847
Practice Address - Country:US
Practice Address - Phone:580-421-8700
Practice Address - Fax:580-421-8785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-25
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center