Healthcare Provider Details

I. General information

NPI: 1841779444
Provider Name (Legal Business Name): IVA COLLINS FAMILY SUPPORT PROVI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2018
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W. MAIN ST.
BARNSDALL OK
74002-0000
US

IV. Provider business mailing address

401 W. MAIN ST.
BARNSDALL OK
74002-0000
US

V. Phone/Fax

Practice location:
  • Phone: 918-847-3527
  • Fax: 918-777-9018
Mailing address:
  • Phone: 918-847-3527
  • Fax: 918-777-9018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: