Healthcare Provider Details

I. General information

NPI: 1255695201
Provider Name (Legal Business Name): SHORTGRASS COMMUNITY HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 06/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E SYCAMORE ST
HOLLIS OK
73550-1436
US

IV. Provider business mailing address

400 E SYCAMORE ST
HOLLIS OK
73550-1436
US

V. Phone/Fax

Practice location:
  • Phone: 580-688-2800
  • Fax: 580-688-2193
Mailing address:
  • Phone: 580-688-2800
  • Fax: 580-688-2193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MRS. JANET TIPTON
Title or Position: OFFICE MANAGER
Credential:
Phone: 580-688-2800