Healthcare Provider Details

I. General information

NPI: 1912212838
Provider Name (Legal Business Name): GLACIER HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2010
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 W. 15TH STREET BUILDING 400, SUITE B
EDMOND OK
73013-3688
US

IV. Provider business mailing address

416 W 15TH ST BUILDING 400, SUITE B
EDMOND OK
73013-3747
US

V. Phone/Fax

Practice location:
  • Phone: 405-285-8900
  • Fax: 405-285-8921
Mailing address:
  • Phone: 405-285-8900
  • Fax: 405-285-8921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: MR. CHAD EMERY HUFFMYER
Title or Position: PRESIDENT
Credential:
Phone: 405-285-8900