=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942366810
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE ATOKA GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 S VIRGINIA AVE
-----------------------------------------------------
City | ATOKA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74525-3246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-889-2500
-----------------------------------------------------
Fax | 580-889-2888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1901 RICKETY LN STE 208
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75703-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-534-8667
-----------------------------------------------------
Fax | 903-509-0026
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | CARLA POWER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 903-534-8667
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | NH0302-0302
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------