Basic Information
| Provider Information | |||||||||
| NPI: | 1386775039 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOPE COMMUNITY SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4720 S SHIELDS BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731293210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056321900 | ||||||||
| FaxNumber: | 4056321976 | ||||||||
| Practice Location | |||||||||
| Address1: | 4720 S SHIELDS BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731293210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056321900 | ||||||||
| FaxNumber: | 4056321976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 12/04/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LABOON | ||||||||
| AuthorizedOfficialFirstName: | STAND | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4056321900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MPA, CBHE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 100734350A | 05 | OK | MEDICAID | 557 | 01 | OK | ODMHSAS | OTHER |