Healthcare Provider Details

I. General information

NPI: 1811095235
Provider Name (Legal Business Name): INDIAN TERRITORY LONG TERM CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 11/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N NESHOBA ST
TISHOMINGO OK
73460-1739
US

IV. Provider business mailing address

105 N NESHOBA ST
TISHOMINGO OK
73460-1739
US

V. Phone/Fax

Practice location:
  • Phone: 580-371-0015
  • Fax:
Mailing address:
  • Phone: 580-371-0015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number100627980E
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number100627980A
License Number StateOK

VIII. Authorized Official

Name: MRS. RHONDA GAIL HENDRIX
Title or Position: OWNER
Credential: MSARNPC
Phone: 580-371-2106