1508987959 NPI number — STATE OF OKLAHOMA; DBA:BILL WILLIS COMMUNITY MENTAL HEALTH CENTER

Table of content: (NPI 1508987959)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508987959 NPI number — STATE OF OKLAHOMA; DBA:BILL WILLIS COMMUNITY MENTAL HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF OKLAHOMA; DBA:BILL WILLIS COMMUNITY MENTAL HEALTH CENTER
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:
1508987959
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 S. HENSLEY DR
Provider Second Line Business Mailing Address:
P.O. BOX 558
Provider Business Mailing Address City Name:
TAHLEQUAH
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74465-0558
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-207-3049
Provider Business Mailing Address Fax Number:
918-207-3065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 S. HENSLEY DR
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:
74465-0558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-207-3049
Provider Business Practice Location Address Fax Number:
918-207-3065
Provider Enumeration Date:
04/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KINNEY
Authorized Official First Name:
WALTER
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
DIRECTOR OF PHARMACY
Authorized Official Telephone Number:
918-207-3049

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  36-4537 , 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: 29393 . This is a "STATE BNDD CONTROL NUMBER" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 364537 . This is a "STATE BOARD OF PHARMACY L" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com