Provider Demographics
NPI:1093890352
Name:CITY OF WAGONER
Entity Type:Organization
Organization Name:CITY OF WAGONER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-538-8278
Mailing Address - Street 1:PO BOX 406
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74477-0406
Mailing Address - Country:US
Mailing Address - Phone:800-538-8278
Mailing Address - Fax:580-628-2273
Practice Address - Street 1:300 SE 3RD ST
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-5726
Practice Address - Country:US
Practice Address - Phone:800-538-8278
Practice Address - Fax:580-628-2273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKEMS0143416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731011975001OtherBCBS PROVIDER NUMBER
OK100818530AMedicaid
OK731011975001OtherBCBS PROVIDER NUMBER