Basic Information
| Provider Information | |||||||||
| NPI: | 1780136705 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHOCTAW NATION HEALTH SERVICES AUTHORITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CHOCTAW WAY | ||||||||
| Address2: | |||||||||
| City: | TALIHINA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745712022 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 109 KERR AVE | ||||||||
| Address2: | |||||||||
| City: | POTEAU | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749535270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186491100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2016 | ||||||||
| LastUpdateDate: | 10/25/2016 | ||||||||
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| AuthorizedOfficialLastName: | HILL | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9185677140 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | PT5210 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.