Healthcare Provider Details

I. General information

NPI: 1790006112
Provider Name (Legal Business Name): CHICKASAW NATION DIVISION OF HEALTH CHICKASAW NATION MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 STONECIPHER BLVD.
ADA OK
74820-3439
US

IV. Provider business mailing address

1925 WARRIOR WAY
ADA OK
74820
US

V. Phone/Fax

Practice location:
  • Phone: 580-421-4570
  • Fax: 580-421-6283
Mailing address:
  • Phone: 580-421-4570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier370180
Identifier TypeOTHER
Identifier State
Identifier IssuerMEDICARE #

VIII. Authorized Official

Name: KIRBI MEEKS
Title or Position: CONTRACT MANAGEMENT COORDINATOR
Credential:
Phone: 580-421-4570