1962465591 NPI number — HEALTHBACK OF NW OKLAHOMA, INC.

Table of content: (NPI 1962465591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962465591 NPI number — HEALTHBACK OF NW OKLAHOMA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHBACK OF NW OKLAHOMA, 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:
1962465591
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16211 N MAY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDMOND
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73013-8871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-842-1700
Provider Business Mailing Address Fax Number:
405-767-1695

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 S 4TH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ENID
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73701-5804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-233-4217
Provider Business Practice Location Address Fax Number:
580-233-3924
Provider Enumeration Date:
04/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CURTIS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
405-842-1700

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  7574 , 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: 100262830A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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