Basic Information
| Provider Information | |||||||||
| NPI: | 1568631885 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SEQUOYAH COUNTY CITY OF SALLISAW HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SEQUOYAH MEMORIAL HOSPITAL OCCUPATIONAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 213 E REDWOOD AVE | ||||||||
| Address2: | PO BOX 505 | ||||||||
| City: | SALLISAW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749552811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187741100 | ||||||||
| FaxNumber: | 9187741103 | ||||||||
| Practice Location | |||||||||
| Address1: | 213 E REDWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | SALLISAW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749552811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187741100 | ||||||||
| FaxNumber: | 9187741103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2008 | ||||||||
| LastUpdateDate: | 01/29/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KNOKE | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9187741100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SEQUOYAH COUNTY CITY OF SALLISAW HOSPITAL AUTHORITY | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 7028 | OK | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 100700190P | 05 | OK | MEDICAID |