Basic Information
| Provider Information | |||||||||
| NPI: | 1639239023 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE SERVICE CORPORATION OF OKLAHOMA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE OF OKLAHOMA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 N CRAYCROFT RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857111448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207476600 | ||||||||
| FaxNumber: | 5207476613 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 N HIGH ST | ||||||||
| Address2: | |||||||||
| City: | ANTLERS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745232238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802985779 | ||||||||
| FaxNumber: | 5802985016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOERNING | ||||||||
| AuthorizedOfficialFirstName: | BREEANN | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | AR AND BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5207476600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 100750190M | 05 | OK | MEDICAID |