Basic Information
| Provider Information | |||||||||
| NPI: | 1053517136 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RED ROCK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 747 W JUNIPER DR | ||||||||
| Address2: | |||||||||
| City: | MUSTANG | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730643042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054011962 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 N CHOCTAW AVE | ||||||||
| Address2: | |||||||||
| City: | EL RENO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730362624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052623209 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HUMPHREY | ||||||||
| AuthorizedOfficialFirstName: | COURTNEY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CARE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4052623209 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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| AuthorizedOfficialCredential: | BHRS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.