Provider Demographics
NPI:1164755724
Name:QUARTZ RESORT SEVERCIES
Entity Type:Organization
Organization Name:QUARTZ RESORT SEVERCIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:KNIGHT
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-728-1173
Mailing Address - Street 1:7932 NICHOLSON DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-5539
Mailing Address - Country:US
Mailing Address - Phone:405-728-1173
Mailing Address - Fax:
Practice Address - Street 1:7932 NICHOLSON DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73162-5539
Practice Address - Country:US
Practice Address - Phone:405-728-1173
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty