Basic Information
| Provider Information | |||||||||
| NPI: | 1649330242 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHICKASAW NATION DIVISION OF HEALTH CHICKASAW NATION MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHICKASAW NATION TISHOMINGO CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1925 WARRIOR WAY | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804214570 | ||||||||
| FaxNumber: | 5804216283 | ||||||||
| Practice Location | |||||||||
| Address1: | 817 E 6TH ST | ||||||||
| Address2: | |||||||||
| City: | TISHOMINGO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734601800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803712392 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 06/10/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARPENTER | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACT MANAGEMENT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5804214570 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.