Provider Demographics
NPI:1134704489
Name:TAHLEQUAH MEN'S SHELTER DBA PROJECT OSIYO
Entity Type:Organization
Organization Name:TAHLEQUAH MEN'S SHELTER DBA PROJECT OSIYO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:918-708-2015
Mailing Address - Street 1:118 W KEETOOWAH ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3820
Mailing Address - Country:US
Mailing Address - Phone:918-708-2015
Mailing Address - Fax:
Practice Address - Street 1:118 W KEETOOWAH ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3820
Practice Address - Country:US
Practice Address - Phone:918-708-2015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No251V00000XAgenciesVoluntary or Charitable
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care