1447594502 NPI number — EASTERN OKLAHOMA YOUTH SERVICES, INC.

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 1447594502 NPI number — EASTERN OKLAHOMA YOUTH SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN OKLAHOMA YOUTH SERVICES, 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:
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:
1447594502
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2626 S 14TH ST
Provider Second Line Business Mailing Address:
SUITE A20
Provider Business Mailing Address City Name:
MCALESTER
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74501-7383
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-420-5325
Provider Business Mailing Address Fax Number:
918-420-5327

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
511 COLLEGE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAHLEQUAH
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74464-4747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-453-0600
Provider Business Practice Location Address Fax Number:
918-453-0628
Provider Enumeration Date:
11/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KELLEY
Authorized Official First Name:
KENT
Authorized Official Middle Name:
RYAN
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
918-420-5325

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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