1255702791 NPI number — TIDWELL FAMILY HEALTHCARE, LLC

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 1255702791 NPI number — TIDWELL FAMILY HEALTHCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIDWELL FAMILY HEALTHCARE, 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:
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:
1255702791
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
225 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILBURTON
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74578-4045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-465-9300
Provider Business Mailing Address Fax Number:
918-465-9303

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1209 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUINTON
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-469-2600
Provider Business Practice Location Address Fax Number:
918-469-2208
Provider Enumeration Date:
10/09/2015

Additional Information

Authorized Official

Authorized Official Last Name:
TIDWELL
Authorized Official First Name:
DARREN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
918-465-9300

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH 6106-6106 , 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)





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