Healthcare Provider Details

I. General information

NPI: 1831190107
Provider Name (Legal Business Name): COUNTRY STYLE HEALTH CARE INC IX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 S 5TH ST
HENRYETTA OK
74437-5203
US

IV. Provider business mailing address

121 S 5TH ST
HENRYETTA OK
74437-5203
US

V. Phone/Fax

Practice location:
  • Phone: 918-650-9133
  • Fax: 918-650-9135
Mailing address:
  • Phone: 918-650-9133
  • Fax: 918-650-9135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHC7689
License Number StateOK

VIII. Authorized Official

Name: JACKIE C BROWNE
Title or Position: VP OF OPERATIONS
Credential:
Phone: 918-465-2626