1114220191 NPI number — SUMMIT HEALTHCARE RECEIVERSHIP LLC

Table of content: (NPI 1114220191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114220191 NPI number — SUMMIT HEALTHCARE RECEIVERSHIP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMIT HEALTHCARE RECEIVERSHIP LLC
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:
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:
1114220191
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1218
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NICOMA PARK
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73066-1218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-769-7990
Provider Business Mailing Address Fax Number:
405-769-7970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 N. 6TH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKEENE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-822-4441
Provider Business Practice Location Address Fax Number:
580-822-4431
Provider Enumeration Date:
12/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GOODMAN
Authorized Official First Name:
RANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
RECEIVER
Authorized Official Telephone Number:
405-769-7990

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH0601 , 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)





Copyright © 2007-2025 www.npivalidator.com