1912248980 NPI number — MCCURTAIN MEMORIAL MEDICAL MANAGEMENT, INC.

Table of content: (NPI 1912248980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912248980 NPI number — MCCURTAIN MEMORIAL MEDICAL MANAGEMENT, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCCURTAIN MEMORIAL MEDICAL MANAGEMENT, 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:
1912248980
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 E LINCOLN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IDABEL
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74745-7300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-208-3103
Provider Business Mailing Address Fax Number:
580-208-3199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 E TERRI DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALLIANT
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74764-6801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-933-9025
Provider Business Practice Location Address Fax Number:
580-933-9027
Provider Enumeration Date:
03/15/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
KENA
Authorized Official Middle Name:
CHEREE
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
580-208-3103

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100700920B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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