MEDICARE: CHICKASAW NATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1922397140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICKASAW NATION

Provider Business Mailing Address
First Line	:	1603 S GREEN AVE
Second Line	:	BOX 1620
City	:	PURCELL
State	:	OK
Zip	:	73080-6210
Country	:	US
Telephone Number	:	405-527-4973
Fax Number	:	405-527-8058

Provider Business Practice Location Address
First Line	:	1603 S GREEN AVE
Second Line	:	BOX 1620
City	:	PURCELL
State	:	OK
Zip	:	73080-6210
Country	:	US
Telephone Number	:	405-527-4973
Fax Number	:	405-527-8058

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. TERRY L. SMITH
Credential	:
Telephone Number	:	405-767-8942

Provider Enumeration Date	:	03/29/2011
Last Update Date	:	03/29/2011

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Directions to “CHICKASAW NATION ” Practice Location

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