Healthcare Provider Details

I. General information

NPI: 1891506960
Provider Name (Legal Business Name): TRIAD COMPLETE HEALTHCARE A12 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2025
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 N ROCKFORD RD STE A
ARDMORE OK
73401-2541
US

IV. Provider business mailing address

2703 N 14TH ST
PONCA CITY OK
74601-1738
US

V. Phone/Fax

Practice location:
  • Phone: 580-251-7104
  • Fax:
Mailing address:
  • Phone: 580-749-7846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW BINTZ
Title or Position: CEO
Credential:
Phone: 970-270-7929