1528408523 NPI number — ALTUS PREMIER HEALTH CLINIC P.L.L.C.

Table of content: (NPI 1528408523)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528408523 NPI number — ALTUS PREMIER HEALTH CLINIC P.L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALTUS PREMIER HEALTH CLINIC P.L.L.C.
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:
1528408523
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
304 S PARK LN
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
ALTUS
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73521-5753
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-379-6550
Provider Business Mailing Address Fax Number:
580-379-6559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 S PARK LN STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTUS
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73521-5754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-379-6550
Provider Business Practice Location Address Fax Number:
580-379-6559
Provider Enumeration Date:
07/05/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DAWOD
Authorized Official First Name:
ABDALLAH
Authorized Official Middle Name:
S
Authorized Official Title or Position:
M.D.
Authorized Official Telephone Number:
580-379-6550

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  24330 , 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)

  • Identifier: 200053860B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200527450A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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