Basic Information
| Provider Information | |||||||||
| NPI: | 1316900095 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHOCTAW NATION OF OKLAHOMA-PRINCIPAL CHIEF | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TOTAL CARE HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 702 BRYAN DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | DURANT | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747017000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809313636 | ||||||||
| FaxNumber: | 5809319016 | ||||||||
| Practice Location | |||||||||
| Address1: | 702 BRYAN DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | DURANT | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747017000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809313636 | ||||||||
| FaxNumber: | 5809319016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5809313636 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | HO4228 | OK | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | SW22676 | 01 | OK | SUBMITTER ID NUMBER | OTHER | HO4228 | 01 | OK | HOSPICE LICENSURE | OTHER |