Basic Information
| Provider Information | |||||||||
| NPI: | 1972802346 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHICKASAW NATION FRS - NORMAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 MARSHALL AVE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730728033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057678940 | ||||||||
| FaxNumber: | 4057678949 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 MARSHALL AVE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730728033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057678940 | ||||||||
| FaxNumber: | 4057678949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2011 | ||||||||
| LastUpdateDate: | 03/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 404057678942 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.