Provider Demographics
NPI:1336332303
Name:SHELTERED WORK ACTIVITY PROGRAM
Entity Type:Organization
Organization Name:SHELTERED WORK ACTIVITY PROGRAM
Other - Org Name:SWAP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:BREEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:918-683-8162
Mailing Address - Street 1:210 E OKMULGEE ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-5453
Mailing Address - Country:US
Mailing Address - Phone:918-683-8162
Mailing Address - Fax:918-687-5368
Practice Address - Street 1:210 E OKMULGEE ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-5453
Practice Address - Country:US
Practice Address - Phone:918-683-8162
Practice Address - Fax:918-687-5368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100682680AMedicaid