Healthcare Provider Details

I. General information

NPI: 1770544769
Provider Name (Legal Business Name): STATE OF OKLAHOMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 E 4TH ST
OKMULGEE OK
74447-3942
US

IV. Provider business mailing address

PO BOX 2506
OKMULGEE OK
74447-8501
US

V. Phone/Fax

Practice location:
  • Phone: 918-293-5155
  • Fax: 918-293-5407
Mailing address:
  • Phone: 918-293-5155
  • Fax: 918-293-5407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number3
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number3
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number13
License Number StateOK

VIII. Authorized Official

Name: MRS. SHELLEY PERKINS
Title or Position: CLINICAL DIRECTOR
Credential: CO,PLO,BOCOC,C.PED.
Phone: 918-293-5155