Basic Information
| Provider Information | |||||||||
| NPI: | 1538155163 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MORTON COMPREHENSIVE HEALTH SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NOWATA FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1334 N LANSING AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741065907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185872171 | ||||||||
| FaxNumber: | 9182739946 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 S LOCUST ST | ||||||||
| Address2: | |||||||||
| City: | NOWATA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740483660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182739911 | ||||||||
| FaxNumber: | 9182739946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 07/24/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | SAUNYA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9182956107 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MORTON COMPREHENSIVE HEALTH SERVICES, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1538155163 | 01 | OK | NPI | OTHER | 100768880J | 05 | OK | MEDICAID | WCDPG | 01 | OK | MEDICARE | OTHER |