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General NPI Number Information
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NPI Number | 1730180894
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Entity Type | Organization
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Legal Business Name | INTEGRIS BASS BAPTIST HEALTH CENTER
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Dates
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Enumeration Date | 08/10/2005
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Last Update Date | 04/14/2025
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Provider Practice Location Address
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Address Line | 158 E SUNSET DR STE B
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City | MEDFORD
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State | OK
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Zip | 73759-2427
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Country | US
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Telephone | 580-395-2319
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 200731
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City | DALLAS
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State | TX
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Zip | 75320-0731
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Country | US
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Telephone | 405-252-8400
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Fax |
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Authorized Official
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Title or Position | ASSISTANT TREASURER
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Name | DONNA WALLACE
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Credential |
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Telephone | 636-359-4890
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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