1063188878 NPI number — NORTHEASTERN OKLAHOMA COMMUNITY HEALTH CENTERS, INC.

Table of content: BLAKE AUSTIN MANN M.D. (NPI 1629210059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063188878 NPI number — NORTHEASTERN OKLAHOMA COMMUNITY HEALTH CENTERS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEASTERN OKLAHOMA COMMUNITY HEALTH CENTERS, 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:
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:
1063188878
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 751
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HULBERT
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74441-0751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-772-3390
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 E DOWNING ST STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAHLEQUAH
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74464-3354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-708-3580
Provider Business Practice Location Address Fax Number:
918-506-6041
Provider Enumeration Date:
08/20/2021

Additional Information

Authorized Official

Authorized Official Last Name:
ROSENTHAL
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
918-772-3390

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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