Organization
EDWIN FAIR CMHC
Active
Organization
EDWIN FAIR CMHC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MISTY DAWN DANIELS MA (EXECUTIVE DIRECTOR)
(580) 762-7561
Entity
Organization
Contact information
Practice address
201 E CHESTNUT AVE, PONCA CITY, OK 74601-4311
(580) 762-7561
(580) 762-2576
Mailing address
1500 N 6TH ST, PONCA CITY, OK 74601-2827
(580) 762-7561
(580) 762-2576
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100749540E
—
OK
05
—
100749540T
—
OK
05
—
100749540X
—
OK
Enumeration date
06/24/2008
Last updated
10/08/2012
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