Healthcare Provider Details

I. General information

NPI: 1013133420
Provider Name (Legal Business Name): PRAGUE HEALTHCARE ALLIANCE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1322 KLABZUBA
PRAGUE OK
74864
US

IV. Provider business mailing address

PO BOX S
PRAGUE OK
74864-1090
US

V. Phone/Fax

Practice location:
  • Phone: 405-567-4922
  • Fax: 405-567-4290
Mailing address:
  • Phone: 405-567-4922
  • Fax: 405-567-4290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. JOAN WALTERS
Title or Position: CEO ADMINISTRATOR
Credential:
Phone: 405-567-4922