Basic Information
| Provider Information | |||||||||
| NPI: | 1093739120 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRIS BLACKWELL HOME HEALTH & HOSPICE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | INTEGRIS BLACKWELL REGIONAL HOSPITAL HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 706 S 13TH STREET | ||||||||
| Address2: | |||||||||
| City: | BLACKWELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 746313700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803632311 | ||||||||
| FaxNumber: | 5803639352 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 S 13TH ST | ||||||||
| Address2: | |||||||||
| City: | BLACKWELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 746313700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803632311 | ||||||||
| FaxNumber: | 5803639352 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 06/09/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLTSFORD | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, BUSINESS OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6154657466 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 7335 | OK | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 100700340B | 05 | OK | MEDICAID |