Basic Information
Provider Information | |||||||||
NPI: | 1275799645 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHEROKEE NATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHEROKEE NATION OUTPATIENT HEALTH CENTER | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1069 | ||||||||
Address2: |   | ||||||||
City: | TAHLEQUAH | ||||||||
State: | OK | ||||||||
PostalCode: | 744651069 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5392342694 | ||||||||
FaxNumber: | 5392342475 | ||||||||
Practice Location | |||||||||
Address1: | 100 S BLISS AVE | ||||||||
Address2: |   | ||||||||
City: | TAHLEQUAH | ||||||||
State: | OK | ||||||||
PostalCode: | 744642512 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184583100 | ||||||||
FaxNumber: | 9184583610 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2008 | ||||||||
LastUpdateDate: | 11/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JONES | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: | ROBERT | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR, HEALTH SERVICES | ||||||||
AuthorizedOfficialTelephone: | 9184583100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DDS | ||||||||
NPICertificationDate: | 11/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
No ID Information.