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General NPI Number Information
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NPI Number | 1891506960
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Entity Type | Organization
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Legal Business Name | TRIAD COMPLETE HEALTHCARE A12 LLC
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Dates
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Enumeration Date | 01/16/2025
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Last Update Date | 03/25/2025
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Provider Practice Location Address
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Address Line | 2002 12TH AVE NW
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City | ARDMORE
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State | OK
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Zip | 73401-1227
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Country | US
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Telephone | 580-251-7104
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Fax |
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Provider Business Mailing Address
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Address Line | 2703 N 14TH ST
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City | PONCA CITY
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State | OK
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Zip | 74601-1738
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Country | US
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Telephone | 580-749-7846
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MATTHEW BINTZ
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Credential |
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Telephone | 970-270-7929
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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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 | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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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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