Healthcare Provider Details

I. General information

NPI: 1891718086
Provider Name (Legal Business Name): MAYES COUNTY HMA HOME HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 WOODLAWN AVE
TAHLEQUAH OK
74464-3317
US

IV. Provider business mailing address

PO BOX 51266
LAFAYETTE LA
70505-1266
US

V. Phone/Fax

Practice location:
  • Phone: 918-824-7744
  • Fax: 918-824-6319
Mailing address:
  • Phone: 337-233-1307
  • Fax: 337-443-4154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number7232
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100700040D
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name: NICHOLAS GACHASSIN III
Title or Position: SECRETARY/TREASURER
Credential:
Phone: 337-233-1307