Healthcare Provider Details

I. General information

NPI: 1891908851
Provider Name (Legal Business Name): COMMUNITY ACTION DEVELOPMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 SOUTH 3RD ST
SENTINEL OK
73664
US

IV. Provider business mailing address

122 SOUTH 3RD ST
SENTINEL OK
73664
US

V. Phone/Fax

Practice location:
  • Phone: 580-393-2216
  • Fax: 580-393-2214
Mailing address:
  • Phone: 580-393-2216
  • Fax: 580-393-2214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateOK

VIII. Authorized Official

Name: PEGGY SUBIA
Title or Position: PROJECT DIRECTOR
Credential:
Phone: 580-393-2216