Basic Information
Provider Information | |||||||||
NPI: | 1205417219 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4913 W RENO AVE | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731276339 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4059484900 | ||||||||
FaxNumber: | 4059484933 | ||||||||
Practice Location | |||||||||
Address1: | 309 S ANN ARBOR AVE | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731281112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4059484900 | ||||||||
FaxNumber: | 4059484933 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/20/2021 | ||||||||
LastUpdateDate: | 04/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SUNDAY-ALLEN | ||||||||
AuthorizedOfficialFirstName: | ROBYN | ||||||||
AuthorizedOfficialMiddleName: | RACHELLE | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 4059484900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MPH, RN | ||||||||
NPICertificationDate: | 04/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.