1619710654 NPI number — TAJAHAE ANTONIECE CANTRELL BHCMII

Table of content: TAJAHAE ANTONIECE CANTRELL BHCMII (NPI 1619710654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619710654 NPI number — TAJAHAE ANTONIECE CANTRELL BHCMII

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANTRELL
Provider First Name:
TAJAHAE
Provider Middle Name:
ANTONIECE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BHCMII
Provider Gender Code:
F

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:
1619710654
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1220 WYLIE RD APT 195
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORMAN
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73072-5936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORMAN
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73071-5300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-360-5100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/17/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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