Healthcare Provider Details

I. General information

NPI: 1265518203
Provider Name (Legal Business Name): KICKAPOO TRIBAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105365 S. HWY 102 BUILDING M
MCLOUD OK
74851
US

IV. Provider business mailing address

PO BOX 1360
MCLOUD OK
74851-1360
US

V. Phone/Fax

Practice location:
  • Phone: 405-964-2081
  • Fax: 405-964-2053
Mailing address:
  • Phone: 405-964-2081
  • Fax: 405-964-2053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MR. WAYNE IRION
Title or Position: HEALTH DIRECTOR
Credential:
Phone: 405-964-2081