1649280702 NPI number — OKLAHOMA KIDNEY CENTER, INC.

Table of content: (NPI 1649280702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649280702 NPI number — OKLAHOMA KIDNEY CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OKLAHOMA KIDNEY CENTER, 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:
INTERNAL MEDICINE 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:
1649280702
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1513
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORMAN
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73070-1513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-321-5683
Provider Business Mailing Address Fax Number:
405-329-0486

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 SW 59TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73119-7027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-682-0721
Provider Business Practice Location Address Fax Number:
405-682-0757
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
405-682-0721

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  2596 , 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: 100129880A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100742430A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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