Basic Information
| Provider Information | |||||||||
| NPI: | 1275945974 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRITON HEALTH PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 446 | ||||||||
| Address2: | 128 W. MAIN STREET | ||||||||
| City: | VIAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749620446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187735228 | ||||||||
| FaxNumber: | 9187738482 | ||||||||
| Practice Location | |||||||||
| Address1: | 128 W. MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | VIAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187735228 | ||||||||
| FaxNumber: | 9187738482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2014 | ||||||||
| LastUpdateDate: | 05/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | CARY | ||||||||
| AuthorizedOfficialMiddleName: | PATRICK | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9187735228 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 2148 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.