Healthcare Provider Details

I. General information

NPI: 1093926149
Provider Name (Legal Business Name): SPECIALIZED FOSTER HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 1 BOX 112A
SALLISAW OK
74955-9737
US

IV. Provider business mailing address

RR 1 BOX 112A
SALLISAW OK
74955-9737
US

V. Phone/Fax

Practice location:
  • Phone: 918-775-2628
  • Fax: 918-775-2628
Mailing address:
  • Phone: 918-775-2628
  • Fax: 918-775-2628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State

VIII. Authorized Official

Name: MRS. ZOELLA KAY ROGERS
Title or Position: PROVIDER
Credential:
Phone: 918-775-2628