Basic Information
| Provider Information | |||||||||
| NPI: | 1659961530 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALLIANCE MENTAL HEALTH, LLC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 521147 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741521147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186080380 | ||||||||
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| Practice Location | |||||||||
| Address1: | 217 N WATER AVE | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744642825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186080380 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2021 | ||||||||
| LastUpdateDate: | 08/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | LOBATO | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9186080380 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALLIANCE MENTAL HEALTH, LLOC | ||||||||
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| NPICertificationDate: | 08/13/2021 | ||||||||
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 | 200345410B | 05 | OK | MEDICAID |