Healthcare Provider Details

I. General information

NPI: 1841286283
Provider Name (Legal Business Name): SOUTH COFFEYVILLE SCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E 6TH ST
SOUTH COFFEYVILLE OK
74072-0190
US

IV. Provider business mailing address

600 E 5TH
SOUTH COFFEYVILLE OK
74072-0190
US

V. Phone/Fax

Practice location:
  • Phone: 918-255-6475
  • Fax: 198-255-6230
Mailing address:
  • Phone: 918-255-6475
  • Fax: 198-255-6230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number251K00000X
License Number StateOK

VIII. Authorized Official

Name: MR. SHAW COLT
Title or Position: SUPERINTENDENT
Credential:
Phone: 918-255-6202