=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760202931
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERICK PAYNE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2024
-----------------------------------------------------
Last Update Date | 10/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7777 E US HIGHWAY 66
-----------------------------------------------------
City | EL RENO
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73036-9125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-424-7711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11167 N 2330 RD
-----------------------------------------------------
City | CORN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73024-5020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-929-0021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------