Healthcare Provider Details

I. General information

NPI: 1790602910
Provider Name (Legal Business Name): ABC SUPPORT COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 N BROADWAY ST
CHECOTAH OK
74426-2431
US

IV. Provider business mailing address

PO BOX 1067
CHECOTAH OK
74426-1067
US

V. Phone/Fax

Practice location:
  • Phone: 405-433-6665
  • Fax:
Mailing address:
  • Phone: 405-433-6665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: TOBY BUSCH
Title or Position: OWNER
Credential: OWNER
Phone: 405-433-6665