Basic Information
| Provider Information | |||||||||
| NPI: | 1114266152 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHICKASAW NATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 HOPPE BLVD STE 2 | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748202313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805590810 | ||||||||
| FaxNumber: | 5802725734 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 ARROWHEAD DR | ||||||||
| Address2: | |||||||||
| City: | PAULS VALLEY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730755301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053312300 | ||||||||
| FaxNumber: | 4053312302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2013 | ||||||||
| LastUpdateDate: | 02/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | CRAWFORD | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR COMMUNITY BASED SERVICES- | ||||||||
| AuthorizedOfficialTelephone: | 5805590810 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 171M00000X | OK | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.