Basic Information
Provider Information | |||||||||
NPI: | 1104049733 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PALMER CONTINUUM OF CARE, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TULSA WOMEN AND CHILDREN'S CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 580700 | ||||||||
Address2: |   | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 74158 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9188327764 | ||||||||
FaxNumber: | 9188327765 | ||||||||
Practice Location | |||||||||
Address1: | 2442 MOHAWK BLVD | ||||||||
Address2: |   | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741101519 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184300975 | ||||||||
FaxNumber: | 9184300995 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2007 | ||||||||
LastUpdateDate: | 09/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NEAS | ||||||||
AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9189002404 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MHR | ||||||||
NPICertificationDate: | 09/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X |   |   | Y |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |   |
ID Information
ID | Type | State | Issuer | Description | 100735150 C | 05 | OK |   | MEDICAID | 100735150 B | 05 | OK |   | MEDICAID | 100735150 A | 05 | OK |   | MEDICAID |