1942754510 NPI number — JEFFERSON COUNTY HEALTHCARE AUTHORITY

Table of content: (NPI 1942754510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942754510 NPI number — JEFFERSON COUNTY HEALTHCARE AUTHORITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFERSON COUNTY HEALTHCARE AUTHORITY
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:
WAURIKA FAMILY MEDICAL 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:
1942754510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9172 US HWY 70
Provider Second Line Business Mailing Address:
INTERSECTION HWYS 70&81
Provider Business Mailing Address City Name:
WAURIKA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73573-0090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-228-3669
Provider Business Mailing Address Fax Number:
580-228-2529

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9172 US HWY 70
Provider Second Line Business Practice Location Address:
INTERSECTION HWYS 70 & 81
Provider Business Practice Location Address City Name:
WAURIKA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73573-0090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-228-3669
Provider Business Practice Location Address Fax Number:
580-228-2529
Provider Enumeration Date:
08/11/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GILLESPIE
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
580-228-2344

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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