Provider Demographics
NPI:1437264587
Name:OM TAHLEQUAH, INC.
Entity Type:Organization
Organization Name:OM TAHLEQUAH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-682-1616
Mailing Address - Street 1:3101 CHANDLER RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-4954
Mailing Address - Country:US
Mailing Address - Phone:918-682-1616
Mailing Address - Fax:918-687-4448
Practice Address - Street 1:3101 CHANDLER RD
Practice Address - Street 2:SUITE 105
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-4954
Practice Address - Country:US
Practice Address - Phone:918-682-1616
Practice Address - Fax:918-687-4448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty