Basic Information
| Provider Information | |||||||||
| NPI: | 1184690026 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHOCTAW NATION OF OKLAHOMA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CHOCTAW NATION HEALTH CLINIC-STIGLER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CHOCTAW WAY | ||||||||
| Address2: | |||||||||
| City: | TALIHINA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745712022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185677000 | ||||||||
| FaxNumber: | 9185677041 | ||||||||
| Practice Location | |||||||||
| Address1: | 2204 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | STIGLER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744622822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185677000 | ||||||||
| FaxNumber: | 9185677041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 01/23/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
| AuthorizedOfficialMiddleName: | KAY | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9185677000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.