Basic Information
| Provider Information | |||||||||
| NPI: | 1205923448 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLINTON INDIAN HEALTH CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CLINTON INDIAN HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | RR 1 BOX 3060 | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736019303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803313404 | ||||||||
| FaxNumber: | 5803313565 | ||||||||
| Practice Location | |||||||||
| Address1: | 10321 N 2274 RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736017521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803313404 | ||||||||
| FaxNumber: | 5803313565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 11/26/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRYANT | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AREA DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5803313315 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAWTON INDIAN HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP0904X | Y | Ambulatory Health Care Facilities | Clinic/Center | Public Health, Federal |
ID Information
| ID | Type | State | Issuer | Description | 200119820A | 05 | OK | MEDICAID |