# SALLISAW MEDICAL CLINIC LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1306118377
- **Authorized official:** AMELIA L POITEVINT (OWNER)
- **Authorized official phone:** (918) 790-2890

## Contact information

- **Practice address:** 202 E CHEROKEE AVE, SALLISAW, OK 74955-4600
- **Practice address phone:** (918) 790-2890
- **Practice address fax:** (918) 790-2906
- **Mailing address:** 202 E CHEROKEE AVE, SALLISAW, OK 74955-4600
- **Mailing address phone:** (918) 790-2890
- **Mailing address fax:** (918) 790-2906

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 4825 | OK | Yes |
| 207Q00000X | Family Medicine Physician | 4840 | OK | — |
| 363LF0000X | Family Nurse Practitioner | R0074165 | OK | — |

## Other

- **Enumeration date:** 02/06/2012
- **Last updated:** 02/06/2012