Provider Demographics
NPI:1417072117
Name:SEQUOYAH COUNTY CITY TRUST
Entity Type:Organization
Organization Name:SEQUOYAH COUNTY CITY TRUST
Other - Org Name:SMH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-774-1100
Mailing Address - Street 1:PO BOX 505
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-0505
Mailing Address - Country:US
Mailing Address - Phone:918-774-1100
Mailing Address - Fax:918-774-1103
Practice Address - Street 1:213 E REDWOOD AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-2811
Practice Address - Country:US
Practice Address - Phone:918-774-1100
Practice Address - Fax:918-774-1103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2189261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty