Healthcare Provider Details

I. General information

NPI: 1063296937
Provider Name (Legal Business Name): 401 MEDICAL CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E DOWNING ST
TAHLEQUAH OK
74464-3015
US

IV. Provider business mailing address

401 E DOWNING ST
TAHLEQUAH OK
74464-3015
US

V. Phone/Fax

Practice location:
  • Phone: 918-316-3764
  • Fax: 918-398-8982
Mailing address:
  • Phone: 918-316-3764
  • Fax: 918-398-8982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1013603232
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerNPI
# 2
Identifier201173250A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name: MRS. NANCY E. DENTON
Title or Position: OWNER/ APRN
Credential: APRN-CNP, FNP-BC
Phone: 918-316-6369