1447520820 NPI number — PETERS AGENCY CARE MANAGEMENT LLC

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 1447520820 NPI number — PETERS AGENCY CARE MANAGEMENT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETERS AGENCY CARE MANAGEMENT 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:
PETERS AGENCY BEHAVIORAL HEALTH
Provider Other Organization Name Type Code:
4
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:
1447520820
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 886
Provider Second Line Business Mailing Address:
926 E. CHEROKEE
Provider Business Mailing Address City Name:
SALLISAW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74955
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-775-6555
Provider Business Mailing Address Fax Number:
918-775-6587

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
926 E. CHEROKEE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALLISAW
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-775-6555
Provider Business Practice Location Address Fax Number:
918-775-6587
Provider Enumeration Date:
01/03/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PHILPOT
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
GAYLE
Authorized Official Title or Position:
MANAGING OFFICER
Authorized Official Telephone Number:
918-775-0250

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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