Provider Demographics
NPI:1073828737
Name:SE EMS OF OKLAHOMA, LLC
Entity Type:Organization
Organization Name:SE EMS OF OKLAHOMA, LLC
Other - Org Name:SOUTHEAST EMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:NEWBOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-315-0886
Mailing Address - Street 1:PO BOX 1800
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-1800
Mailing Address - Country:US
Mailing Address - Phone:479-243-9819
Mailing Address - Fax:
Practice Address - Street 1:30177 W CHOCTAW RD
Practice Address - Street 2:
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-3558
Practice Address - Country:US
Practice Address - Phone:479-243-9819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-18
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKEMS-4593416L0300X
AR8033416L0300X
OKEMS-4793416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200412300AMedicaid
AR210183715Medicaid