=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982263752
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHORTGRASS COMMUNITY HEALTH CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2019
-----------------------------------------------------
Last Update Date | 12/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 S HUDSON ST
-----------------------------------------------------
City | ALTUS
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73521-4215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-688-2800
-----------------------------------------------------
Fax | 580-688-2193
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 EAST SYCAMORE STREET
-----------------------------------------------------
City | HOLLIS
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 680-688-2800
-----------------------------------------------------
Fax | 580-886-2193
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JANET LYNN TIPTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 680-688-2800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------