Healthcare Provider Details

I. General information

NPI: 1598053993
Provider Name (Legal Business Name): CITIZEN POTAWATOMI NATION WEST CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 11/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 GRAND CASINO BLVD
SHAWNEE OK
74804-1005
US

IV. Provider business mailing address

781 GRAND CASINO BLVD
SHAWNEE OK
74804-1005
US

V. Phone/Fax

Practice location:
  • Phone: 405-964-5770
  • Fax: 405-964-5785
Mailing address:
  • Phone: 405-964-5770
  • Fax: 405-964-5785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number105576
License Number StateOK

VIII. Authorized Official

Name: DR. DOYLE FORTNEY
Title or Position: WEST CLINIC MANAGER
Credential:
Phone: 405-964-5770