1639239023 NPI number — PROVIDENCE SERVICE CORPORATION OF OKLAHOMA

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 1639239023 NPI number — PROVIDENCE SERVICE CORPORATION OF OKLAHOMA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE SERVICE CORPORATION OF OKLAHOMA
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:
1639239023
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
620 N CRAYCROFT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85711-1448
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-747-6600
Provider Business Mailing Address Fax Number:
520-747-6613

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 N HIGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANTLERS
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74523-2238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-298-5779
Provider Business Practice Location Address Fax Number:
580-298-5016
Provider Enumeration Date:
12/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOERNING
Authorized Official First Name:
BREEANN
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
AR AND BILLING MANAGER
Authorized Official Telephone Number:
520-747-6600

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100750190M , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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