Provider Demographics
NPI:1164941670
Name:COMMUNITY HEALTH CENTER OF NORTHEAST OKLAHOMA
Entity Type:Organization
Organization Name:COMMUNITY HEALTH CENTER OF NORTHEAST OKLAHOMA
Other - Org Name:ROUTE 66 HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PEER
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:918-257-8029
Mailing Address - Street 1:PO BOX 705
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:OK
Mailing Address - Zip Code:74331-0705
Mailing Address - Country:US
Mailing Address - Phone:918-257-8029
Mailing Address - Fax:918-257-8042
Practice Address - Street 1:343 S. COMMERCIAL STREET
Practice Address - Street 2:
Practice Address - City:WELCH
Practice Address - State:OK
Practice Address - Zip Code:74369
Practice Address - Country:US
Practice Address - Phone:918-257-8029
Practice Address - Fax:918-257-8042
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:H80CS26585
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-15
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200539480AMedicaid