Healthcare Provider Details

I. General information

NPI: 1366744534
Provider Name (Legal Business Name): NORTHEASTERN OKLAHOMA COMMUNITY HEALTH CENTERS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2010
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E DOWNING ST SUITE 214
TAHLEQUAH OK
74464-3379
US

IV. Provider business mailing address

PO BOX 751
HULBERT OK
74441-0751
US

V. Phone/Fax

Practice location:
  • Phone: 918-431-0202
  • Fax: 918-431-0203
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:

# 1
Identifier200006960E
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

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