Healthcare Provider Details

I. General information

NPI: 1134250731
Provider Name (Legal Business Name): HELEN FARRIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17963 S 543 ROAD
TAHLEQUAH OK
74464
US

IV. Provider business mailing address

PO BOX 807
TAHLEQUAH OK
74465-0807
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-8677
  • Fax:
Mailing address:
  • Phone: 918-456-0704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberRC-1101-1101
License Number StateOK

VII. Legacy identifiers

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

# 1
IdentifierRC-1101-1101
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerSTATE LICENSE

VIII. Authorized Official

Name: HELEN FARRIS
Title or Position: ADMINISTRATOR
Credential:
Phone: 918-456-0704