Basic Information
Provider Information | |||||||||
NPI: | 1952377939 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHOCTAW NATION OF OKLAHOMA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHOCTAW NATION HEALTH CARE CLINIC-MCALESTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 CHOCTAW WAY | ||||||||
Address2: |   | ||||||||
City: | TALIHINA | ||||||||
State: | OK | ||||||||
PostalCode: | 745712022 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9185677000 | ||||||||
FaxNumber: | 9185677041 | ||||||||
Practice Location | |||||||||
Address1: | 1127 S GEORGE NIGH EXPY | ||||||||
Address2: |   | ||||||||
City: | MCALESTER | ||||||||
State: | OK | ||||||||
PostalCode: | 745017143 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9185677000 | ||||||||
FaxNumber: | 9185677041 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/28/2006 | ||||||||
LastUpdateDate: | 07/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JACKSON | ||||||||
AuthorizedOfficialFirstName: | TERESA | ||||||||
AuthorizedOfficialMiddleName: | KAY | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 9185677000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP0904X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Public Health, Federal | 261QP2300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
ID | Type | State | Issuer | Description | 100699600H | 05 | OK |   | MEDICAID |