=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366539132
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TULSA CITY-COUNTY HEALTH DEPARTMENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2006
-----------------------------------------------------
Last Update Date | 06/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 S UTICA AVE
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74104-2203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-594-4706
-----------------------------------------------------
Fax | 918-594-4889
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 315 S UTICA AVE
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74104-2203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-594-4706
-----------------------------------------------------
Fax | 918-594-4889
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIVISION CHIEF, COMMUNITY HEALTH
-----------------------------------------------------
Name | PRISCILLA HAYNES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 918-594-4822
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------