1194803346 NPI number — KICKAPOO TRIBAL HEALTH CENTER

Table of content: (NPI 1194803346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194803346 NPI number — KICKAPOO TRIBAL HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KICKAPOO TRIBAL HEALTH CENTER
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:
1194803346
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105365 S. HWY 102
Provider Second Line Business Mailing Address:
BUILDING M
Provider Business Mailing Address City Name:
MCLOUD
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-964-2081
Provider Business Mailing Address Fax Number:
405-964-7160

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105365 S. HWY 102
Provider Second Line Business Practice Location Address:
BUILDING M
Provider Business Practice Location Address City Name:
MCLOUD
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-964-2081
Provider Business Practice Location Address Fax Number:
405-964-7160
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAHTAPENE
Authorized Official First Name:
JANETTA
Authorized Official Middle Name:
Authorized Official Title or Position:
HEALTH DIRECTOR
Authorized Official Telephone Number:
405-964-2081

Provider Taxonomy Codes

  • Taxonomy code: 332800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3721809 . This is a "NABP" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100245200A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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