Healthcare Provider Details

I. General information

NPI: 1457816746
Provider Name (Legal Business Name): TELEA RENEE THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2019
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426925 E 1090 RD
CHECOTAH OK
74426-5493
US

IV. Provider business mailing address

426925 E 1090 RD
CHECOTAH OK
74426-5493
US

V. Phone/Fax

Practice location:
  • Phone: 918-843-1701
  • Fax: 918-426-5526
Mailing address:
  • Phone: 918-843-1701
  • Fax: 918-426-5526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: