Provider Demographics
NPI:1427034958
Name:INDIAN HEALTH CARE RESOURCE CENTER
Entity Type:Organization
Organization Name:INDIAN HEALTH CARE RESOURCE CENTER
Other - Org Name:INDIAN HEALTH CARE RESOURCE CENTER OF TULSA, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-588-1900
Mailing Address - Street 1:550 S PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-3820
Mailing Address - Country:US
Mailing Address - Phone:918-588-1900
Mailing Address - Fax:918-582-8552
Practice Address - Street 1:550 SOUTH PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-3820
Practice Address - Country:US
Practice Address - Phone:918-588-1900
Practice Address - Fax:918-582-8552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
OK371806261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK37-1806OtherFQHC MEDICARE ID/NUMBER
OK100732910AMedicaid
OK=========OtherMEDICARE-NOVITAS