Basic Information
| Provider Information | |||||||||
| NPI: | 1558458794 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WATONGA INDIAN HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WATONGA INDIAN HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | RR 1 BOX 34A | ||||||||
| Address2: | |||||||||
| City: | WATONGA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737729706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5806234991 | ||||||||
| FaxNumber: | 5806235490 | ||||||||
| Practice Location | |||||||||
| Address1: | RR 1 BOX 34A | ||||||||
| Address2: | |||||||||
| City: | WATONGA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737729706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5806234991 | ||||||||
| FaxNumber: | 5806235490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 11/26/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRYANT | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5803313315 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAWTON INDIAN HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 200119860A | 05 | OK | MEDICAID |