Basic Information
| Provider Information | |||||||||
| NPI: | 1104198936 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EL RENO INDIAN HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | INDIAN HEALTH SERVICE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 N PARKVIEW DRIVE | ||||||||
| Address2: | |||||||||
| City: | EL RENO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803313300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1801 N PARKVIEW DRIVE | ||||||||
| Address2: | |||||||||
| City: | EL RENO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803313300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2012 | ||||||||
| LastUpdateDate: | 09/10/2013 | ||||||||
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| AuthorizedOfficialLastName: | CLELLAND | ||||||||
| AuthorizedOfficialFirstName: | CARMEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5803313314 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEPARTMENT OF HEALTH AND HUMAN SERVICES | ||||||||
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| AuthorizedOfficialCredential: | PHARM.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | R006447 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.