1043273634 NPI number — HEALTHBACK OF WESTERN OKLAHOMA, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043273634 NPI number — HEALTHBACK OF WESTERN OKLAHOMA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHBACK OF WESTERN OKLAHOMA, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043273634
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16211 N MAY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDMOND
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73013-8871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-842-1700
Provider Business Mailing Address Fax Number:
405-767-1695

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 S 22ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICKASHA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73018-2752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-224-3366
Provider Business Practice Location Address Fax Number:
405-224-3362
Provider Enumeration Date:
04/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CURTIS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
405-842-1700

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  7006 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100848530A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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