Healthcare Provider Details

I. General information

NPI: 1649330242
Provider Name (Legal Business Name): CHICKASAW NATION DIVISION OF HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 E 6TH ST
TISHOMINGO OK
73460-1800
US

IV. Provider business mailing address

1925 WARRIOR WAY
ADA OK
74820
US

V. Phone/Fax

Practice location:
  • Phone: 580-371-2392
  • Fax:
Mailing address:
  • Phone: 580-421-4570
  • Fax: 580-421-6283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DENISE CARPENTER
Title or Position: CONTRACT MANAGEMENT COORDINATOR
Credential:
Phone: 580-421-4570