Basic Information
| Provider Information | |||||||||
| NPI: | 1366793424 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHICKASAW NATION MEDICAL CENTER BEH. HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1921 STONECIPHER BLVD | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804214591 | ||||||||
| FaxNumber: | 5804214586 | ||||||||
| Practice Location | |||||||||
| Address1: | 1921 STONECIPHER BLVD | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804214591 | ||||||||
| FaxNumber: | 5804214586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2012 | ||||||||
| LastUpdateDate: | 09/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | UNDERWOOD | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5804214591 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 3927 | OK | Y | Hospitals | General Acute Care Hospital |
No ID Information.