Provider Demographics
NPI:1033279443
Name:PROVIDENCE SERVICE CORPORATION OF OKLAHOMA
Entity Type:Organization
Organization Name:PROVIDENCE SERVICE CORPORATION OF OKLAHOMA
Other - Org Name:PROVIDENCE OF OKLAHOMA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AR AND BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BREEANN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HOERNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-747-6600
Mailing Address - Street 1:620 N CRAYCROFT RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-1448
Mailing Address - Country:US
Mailing Address - Phone:520-747-6600
Mailing Address - Fax:520-747-6613
Practice Address - Street 1:4645 W GORE BLVD STE 5
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5962
Practice Address - Country:US
Practice Address - Phone:580-355-6800
Practice Address - Fax:580-355-0666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========006OtherBCBS LAWTON PIN