Healthcare Provider Details

I. General information

NPI: 1356535637
Provider Name (Legal Business Name): SHELTERED WORK ACTIVITY PROGRAM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 08/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E OKMULGEE ST
MUSKOGEE OK
74403-5453
US

IV. Provider business mailing address

210 E OKMULGEE ST
MUSKOGEE OK
74403-5453
US

V. Phone/Fax

Practice location:
  • Phone: 918-683-8162
  • Fax: 918-687-5368
Mailing address:
  • Phone: 918-683-8162
  • Fax: 918-687-5368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State

VIII. Authorized Official

Name: DR. EDWARD B BREEN
Title or Position: CEO
Credential: PHD
Phone: 918-683-8162