Healthcare Provider Details

I. General information

NPI: 1639472970
Provider Name (Legal Business Name): CARNEGIE INDIAN HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 E. 4TH ST
CARNEGIE OK
73015
US

IV. Provider business mailing address

PO BOX 1120
CARNEGIE OK
73015-1120
US

V. Phone/Fax

Practice location:
  • Phone: 580-654-1100
  • Fax: 580-654-2273
Mailing address:
  • Phone: 580-654-1100
  • Fax: 580-654-2533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number83491
License Number StateOK

VIII. Authorized Official

Name: JOHN DAUGHERTY
Title or Position: AREA DIRECTOR
Credential:
Phone: 405-951-3820