=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336311422
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OKLAHOMA ECONOMIC DEVELOPMENT AUTHORITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2008
-----------------------------------------------------
Last Update Date | 03/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1116 19TH ST
-----------------------------------------------------
City | WOODWARD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73801-2925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-256-8553
-----------------------------------------------------
Fax | 580-254-2825
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 668
-----------------------------------------------------
City | BEAVER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73932-0668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-625-4531
-----------------------------------------------------
Fax | 580-625-3420
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. MIKE BOSTIC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 580-625-4531
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------