1104295500 NPI number — EXCEL MENTAL HEALTH SERVICES, LLC

Table of content: (NPI 1992720528)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104295500 NPI number — EXCEL MENTAL HEALTH SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXCEL MENTAL HEALTH SERVICES, LLC
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:
EXCEL MHS, LLC
Provider Other Organization Name Type Code:
3
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:
1104295500
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 826
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAULS VALLEY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73075-0826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-926-2085
Provider Business Mailing Address Fax Number:
405-926-2089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
513 S WILLOW ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAULS VALLEY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73075-3849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-926-2085
Provider Business Practice Location Address Fax Number:
405-926-2089
Provider Enumeration Date:
09/16/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GARDENHIRE
Authorized Official First Name:
RANDY
Authorized Official Middle Name:
HUGH
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
580-399-3071

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  5643 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 106H00000X , with the licence number: 1147 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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