Basic Information
| Provider Information | |||||||||
| NPI: | 1407859606 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TKG INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GUARDIAN HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3854 AMERICAN WAY STE A | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708164897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252922031 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 209 E JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | HUGO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747434036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803178079 | ||||||||
| FaxNumber: | 5803179275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 06/14/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GINN | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | GERALD | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO EVP | ||||||||
| AuthorizedOfficialTelephone: | 2252993020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 7723 | OK | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 200042940A | 05 | OK | MEDICAID |