Healthcare Provider Details

I. General information

NPI: 1144704107
Provider Name (Legal Business Name): MEDRITE HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 09/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 N BROADWAY AVE
HASKELL OK
74436-9654
US

IV. Provider business mailing address

109 W 6TH ST
OKMULGEE OK
74447-5015
US

V. Phone/Fax

Practice location:
  • Phone: 918-238-1700
  • Fax:
Mailing address:
  • Phone: 918-756-3114
  • Fax: 918-758-1358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200740340A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name: BENJAMIN BRADLEY
Title or Position: CEO
Credential:
Phone: 918-756-3114