Basic Information
| Provider Information | |||||||||
| NPI: | 1245450444 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANADIAN COUNTY | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7905 EAST HIGHWAY 66 | ||||||||
| Address2: | |||||||||
| City: | EL RENO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052620202 | ||||||||
| FaxNumber: | 4052620259 | ||||||||
| Practice Location | |||||||||
| Address1: | 7905 EAST HIGHWAY 66 | ||||||||
| Address2: | |||||||||
| City: | EL RENO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052620202 | ||||||||
| FaxNumber: | 4052620259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2007 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SOUTH | ||||||||
| AuthorizedOfficialFirstName: | JOAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FACILITY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4052620202 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LBP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | K850000246 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 2000727780 | 05 | OK | MEDICAID |