Provider Demographics
NPI:1245568070
Name:PETERS AGENCY HOME CARE, LLC
Entity Type:Organization
Organization Name:PETERS AGENCY HOME CARE, LLC
Other - Org Name:PETERS AGENCY PROVIDER SERVICES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRUDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, RN, CCM, LHCA
Authorized Official - Phone:918-775-6555
Mailing Address - Street 1:1015 EAST CHOCTAW AVENUE
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-5011
Mailing Address - Country:US
Mailing Address - Phone:918-790-7555
Mailing Address - Fax:918-790-7587
Practice Address - Street 1:1015 EAST CHOCTAW AVENUE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-5011
Practice Address - Country:US
Practice Address - Phone:918-790-7555
Practice Address - Fax:918-790-7587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7891251C00000X, 253Z00000X, 3747P1801X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Single Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200202440Medicaid