Provider Demographics
NPI:1548646052
Name:NEXT GENERATION FAMILY MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:NEXT GENERATION FAMILY MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCHOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO,PHD
Authorized Official - Phone:918-201-4502
Mailing Address - Street 1:1102 W CHEROKEE ST STE A
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-4600
Mailing Address - Country:US
Mailing Address - Phone:918-201-4502
Mailing Address - Fax:918-201-4503
Practice Address - Street 1:1102 W CHEROKEE ST STE A
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4600
Practice Address - Country:US
Practice Address - Phone:918-201-4502
Practice Address - Fax:918-201-4503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-06
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4383208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1275754780Medicaid