Provider Demographics
NPI:1407822497
Name:CHOCTAW NATION OF OKLAHOMA
Entity Type:Organization
Organization Name:CHOCTAW NATION OF OKLAHOMA
Other - Org Name:CHOCTAW NATION HEALTH CLINIC-IDABEL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOAR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-567-7000
Mailing Address - Street 1:1 CHOCTAW WAY
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-2022
Mailing Address - Country:US
Mailing Address - Phone:918-567-7000
Mailing Address - Fax:918-567-7041
Practice Address - Street 1:902 E LINCOLN RD
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-7337
Practice Address - Country:US
Practice Address - Phone:918-567-7000
Practice Address - Fax:918-567-7041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100699600UMedicaid
370172Medicare ID - Type Unspecified