Basic Information
| Provider Information | |||||||||
| NPI: | 1790008902 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE OF OKLAHOMA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HUGO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747436237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803267477 | ||||||||
| FaxNumber: | 5803266400 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HUGO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747436237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803267477 | ||||||||
| FaxNumber: | 5803266400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2010 | ||||||||
| LastUpdateDate: | 03/03/2010 | ||||||||
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| AuthorizedOfficialLastName: | BABB | ||||||||
| AuthorizedOfficialFirstName: | ANNJAVETTA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PSRS | ||||||||
| AuthorizedOfficialTelephone: | 5803267477 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | B.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.