Provider Demographics
NPI:1376652180
Name:CHICKASAW NATION DIVISION OF HEALTH
Entity Type:Organization
Organization Name:CHICKASAW NATION DIVISION OF HEALTH
Other - Org Name:OKLAHOMA OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OKLAHOMA OPTICAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:BOATRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-332-2796
Mailing Address - Street 1:1005 N COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2847
Mailing Address - Country:US
Mailing Address - Phone:580-332-2796
Mailing Address - Fax:580-332-3360
Practice Address - Street 1:1005 N COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2847
Practice Address - Country:US
Practice Address - Phone:580-332-2796
Practice Address - Fax:580-421-4523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100768150AMedicaid
OK6218430001Medicare NSC