Healthcare Provider Details

I. General information

NPI: 1194803346
Provider Name (Legal Business Name): KICKAPOO TRIBAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
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

105365 S. HWY 102 BUILDING M
MCLOUD OK
74851
US

V. Phone/Fax

Practice location:
  • Phone: 405-964-2081
  • Fax: 405-964-7160
Mailing address:
  • Phone: 405-964-2081
  • Fax: 405-964-7160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State

VIII. Authorized Official

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