1568587095 NPI number — KIAMICHI COUNCIL ON ALCOHOLISM AND OR OTHER DRUG ABUSE, INC.

Table of content: MRS. SHANNON MARIE SNYDER RD (NPI 1821803123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568587095 NPI number — KIAMICHI COUNCIL ON ALCOHOLISM AND OR OTHER DRUG ABUSE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIAMICHI COUNCIL ON ALCOHOLISM AND OR OTHER DRUG ABUSE, 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:
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:
1568587095
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
307 W ELM ST
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
DURANT
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74701-4109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-924-6692
Provider Business Mailing Address Fax Number:
580-924-7618

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
307 W ELM ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
DURANT
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74701-4109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-924-6692
Provider Business Practice Location Address Fax Number:
580-924-7618
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WHITTEN
Authorized Official First Name:
DORTHEA
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
580-286-3301

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , 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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