Healthcare Provider Details

I. General information

NPI: 1366353799
Provider Name (Legal Business Name): BLANCA CENTENO CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W TAMARACK RD
ALTUS OK
73521-1529
US

IV. Provider business mailing address

401 W TAMARACK RD
ALTUS OK
73521-1529
US

V. Phone/Fax

Practice location:
  • Phone: 580-482-7308
  • Fax: 580-477-2763
Mailing address:
  • Phone: 580-482-7308
  • Fax: 580-477-2763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: