Healthcare Provider Details

I. General information

NPI: 1124029293
Provider Name (Legal Business Name): INTEGRIS BASS BAPTIST HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1084 NICKERSON ST
WAYNOKA OK
73860-1245
US

IV. Provider business mailing address

PO BOX 200731
DALLAS TX
75320-0731
US

V. Phone/Fax

Practice location:
  • Phone: 580-824-2281
  • Fax:
Mailing address:
  • Phone: 405-252-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DONNA WALLACE
Title or Position: ASSISTANT TREASURER
Credential:
Phone: 636-359-4890