Provider Demographics
NPI:1346300027
Name:CHOICES FOR LIFE FOSTER CARE, INC.
Entity Type:Organization
Organization Name:CHOICES FOR LIFE FOSTER CARE, INC.
Other - Org Name:CHOICES FOR LIFE CHECOTAH
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:FELLRATH
Authorized Official - Suffix:
Authorized Official - Credentials:ATTORNEY
Authorized Official - Phone:405-751-0800
Mailing Address - Street 1:4101 PERIMETER CENTER DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2302
Mailing Address - Country:US
Mailing Address - Phone:405-751-0800
Mailing Address - Fax:405-751-6488
Practice Address - Street 1:229 W GENTRY AVE
Practice Address - Street 2:
Practice Address - City:CHECOTAH
Practice Address - State:OK
Practice Address - Zip Code:74426-2439
Practice Address - Country:US
Practice Address - Phone:918-473-1575
Practice Address - Fax:918-473-3185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKK8600134251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========Medicare ID - Type Unspecified