Healthcare Provider Details

I. General information

NPI: 1073164125
Provider Name (Legal Business Name): NORTHEASTERN OKLAHOMA COMMUNITY HEALTH CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 E ROSS BYP
TAHLEQUAH OK
74464-4133
US

IV. Provider business mailing address

PO BOX 751
HULBERT OK
74441-0751
US

V. Phone/Fax

Practice location:
  • Phone: 918-453-9002
  • Fax: 918-453-0328
Mailing address:
  • Phone: 918-772-3390
  • Fax: 918-772-2244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: SCOTT ROSENTHAL
Title or Position: CEO
Credential:
Phone: 918-772-3390