1568753101 NPI number — CATOOSA HOPE CLINIC PLLC

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 1568753101 NPI number — CATOOSA HOPE CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CATOOSA HOPE CLINIC PLLC
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:
CATOOSA HOPE CLINIC
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:
1568753101
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1755 N HIGHWAY 66
Provider Second Line Business Mailing Address:
STE F
Provider Business Mailing Address City Name:
CATOOSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74015-2409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-739-4885
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1755 N HIGHWAY 66
Provider Second Line Business Practice Location Address:
STE F
Provider Business Practice Location Address City Name:
CATOOSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74015-2409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-739-4885
Provider Business Practice Location Address Fax Number:
918-739-4885
Provider Enumeration Date:
05/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LUSSIER
Authorized Official First Name:
KYLA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
918-739-4885

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , 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: 200339530A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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