=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659674455
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHOCTAW NATION OF OKLAHOMA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2010
-----------------------------------------------------
Last Update Date | 01/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 CHOCTAW WAY
-----------------------------------------------------
City | TALIHINA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74571-2022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-567-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 351
-----------------------------------------------------
City | HAILEYVILLE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74546-0351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-329-1509
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | TERESA K JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 918-567-7000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | 4145
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------