1518199876 NPI number — INDIAN TERRITORY HOME HEALTH INC

Table of content: JOHANNA ELLIS (NPI 1457240087)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518199876 NPI number — INDIAN TERRITORY HOME HEALTH INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIAN TERRITORY HOME HEALTH 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:
1518199876
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 E MAIN
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
TISHOMINGO
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73460-2413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-371-9151
Provider Business Mailing Address Fax Number:
580-371-9145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2112 W BROADWAY AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SULPHUR
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73086-4200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-622-3083
Provider Business Practice Location Address Fax Number:
580-622-3085
Provider Enumeration Date:
08/19/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
580-622-3083

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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