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General NPI Number Information
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NPI Number | 1710240825
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Entity Type | Organization
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Legal Business Name | OSAGE NATION PRT
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Dates
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Enumeration Date | 06/22/2012
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Last Update Date | 06/22/2012
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Provider Practice Location Address
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Address Line | 1011 GRANDVIEW AVE
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City | PAWHUSKA
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State | OK
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Zip | 74056-3023
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Country | US
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Telephone | 918-287-5420
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Fax | 918-287-3721
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Provider Business Mailing Address
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Address Line | 5525 HARVARD DR
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City | BARTLESVILLE
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State | OK
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Zip | 74006-8838
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Country | US
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Telephone | 918-287-5420
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Fax | 918-287-3721
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Authorized Official
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Title or Position | COORDINATOR
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Name | MR. LOUIS GRAY I
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Credential | NA
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Telephone | 918-287-5420
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 109
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License Number State | OK
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