Healthcare Provider Details

I. General information

NPI: 1649392457
Provider Name (Legal Business Name): EASTERN OKLAHOMA COUNTY TECHNOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 N CHOCTAW RD
CHOCTAW OK
73020-9017
US

IV. Provider business mailing address

4601 N CHOCTAW RD
CHOCTAW OK
73020-9017
US

V. Phone/Fax

Practice location:
  • Phone: 405-390-4400
  • Fax: 405-390-6637
Mailing address:
  • Phone: 405-390-9591
  • Fax: 405-390-6639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberDC5505-5505
License Number StateOK

VIII. Authorized Official

Name: DARYL A CRUSOE
Title or Position: BUSINESS MANAGER
Credential:
Phone: 405-390-6603