Basic Information
| Provider Information | |||||||||
| NPI: | 1821159922 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PATHWAYS OF OKLAHOMA INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE OF OKLAHOMA | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1161 N EL DORADO PL | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857154607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205701460 | ||||||||
| FaxNumber: | 5207450638 | ||||||||
| Practice Location | |||||||||
| Address1: | 134 N 12TH AVE | ||||||||
| Address2: | |||||||||
| City: | DURANT | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747014718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809246363 | ||||||||
| FaxNumber: | 5809240379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 10/17/2017 | ||||||||
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| AuthorizedOfficialLastName: | POE | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5205701460 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PATHWAYS HEALTH AND COMMUNITY SUPPORT, LLC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | 100750190A | 05 | OK | MEDICAID |