Healthcare Provider Details

I. General information

NPI: 1568504553
Provider Name (Legal Business Name): PROVIDENCE SERVICE CORPORATION OF OKLAHOMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 N 12TH AVE
DURANT OK
74701-4718
US

IV. Provider business mailing address

620 N CRAYCROFT RD
TUCSON AZ
85711-1448
US

V. Phone/Fax

Practice location:
  • Phone: 580-924-6363
  • Fax: 580-924-0379
Mailing address:
  • Phone: 520-747-6694
  • Fax: 520-747-6613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: BREEANN HOERNING
Title or Position: AR BILLING MANAGER
Credential:
Phone: 520-747-6694