Healthcare Provider Details

I. General information

NPI: 1114519774
Provider Name (Legal Business Name): COMMUNITY HEALTH CENTER OF NORTHEAST OKLAHOMA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2021
Last Update Date: 02/05/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2485 N. MAIN ST.
JAY OK
74346
US

IV. Provider business mailing address

P.O. BOX 705
AFTON OK
74331-0705
US

V. Phone/Fax

Practice location:
  • Phone: 918-253-2550
  • Fax: 918-253-2122
Mailing address:
  • Phone: 918-257-8029
  • Fax: 918-257-8042

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: JANET MENDEZ
Title or Position: CEO
Credential:
Phone: 918-257-8029