1720101439 NPI number — CREOKS MENTAL HEALTH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720101439 NPI number — CREOKS MENTAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREOKS MENTAL HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720101439
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4103 S YALE AVE STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74135-6002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-382-7300
Provider Business Mailing Address Fax Number:
918-382-7302

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
323 W. 6TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKMULGEE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-756-9250
Provider Business Practice Location Address Fax Number:
918-756-2126
Provider Enumeration Date:
04/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BLACK
Authorized Official First Name:
BRENT
Authorized Official Middle Name:
M
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
918-756-9411

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  100734620G , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 100734620A , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100734620A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100734620G , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com