Healthcare Provider Details

I. General information

NPI: 1952584518
Provider Name (Legal Business Name): CHEROKEE NATION COMPREHENSIVE CARE AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1387 W FOURTH ST
TAHLEQUAH OK
74464
US

IV. Provider business mailing address

PO BOX 948
TAHLEQUAH OK
74465-0948
US

V. Phone/Fax

Practice location:
  • Phone: 918-431-4111
  • Fax: 918-431-4112
Mailing address:
  • Phone: 918-431-4111
  • Fax: 918-431-4112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License NumberH4142
License Number StateOK

VII. Legacy identifiers

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

# 1
IdentifierH4142
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerCMS

VIII. Authorized Official

Name: SHARON K. HILTON
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 918-453-5599