Healthcare Provider Details

I. General information

NPI: 1629018932
Provider Name (Legal Business Name): KAY COUNTY OKLAHOMA HOSPITAL COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 N 14TH ST
PONCA CITY OK
74601-2035
US

IV. Provider business mailing address

PO BOX 504295
SAINT LOUIS MO
63150-4295
US

V. Phone/Fax

Practice location:
  • Phone: 580-765-3321
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number2273
License Number StateOK

VIII. Authorized Official

Name: MICHAEL PORTACCI
Title or Position: SENIOR VP, GROUP OPERATIONS
Credential:
Phone: 888-373-9600