Basic Information
| Provider Information | |||||||||
| NPI: | 1912248980 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCCURTAIN MEMORIAL MEDICAL MANAGEMENT, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VALLIANT HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 E LINCOLN RD | ||||||||
| Address2: | |||||||||
| City: | IDABEL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747457300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802083100 | ||||||||
| FaxNumber: | 5802083199 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 E TERRI DR | ||||||||
| Address2: | |||||||||
| City: | VALLIANT | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747646801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809339025 | ||||||||
| FaxNumber: | 5809339027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2013 | ||||||||
| LastUpdateDate: | 03/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | WHITMORE | ||||||||
| AuthorizedOfficialFirstName: | RAY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5802083104 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100700920B | 05 | OK | MEDICAID |