Healthcare Provider Details

I. General information

NPI: 1437264587
Provider Name (Legal Business Name): OM TAHLEQUAH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 CHANDLER RD SUITE 105
MUSKOGEE OK
74403-4954
US

IV. Provider business mailing address

3101 CHANDLER RD SUITE 105
MUSKOGEE OK
74403-4954
US

V. Phone/Fax

Practice location:
  • Phone: 918-682-1616
  • Fax: 918-687-4448
Mailing address:
  • Phone: 918-682-1616
  • Fax: 918-687-4448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateOK

VIII. Authorized Official

Name: MR. DAVID E EDWARDS
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 918-682-1616