Provider Demographics
NPI:1457481426
Name:INDIAN TERRITORY LONG TERM CARE, INC.
Entity Type:Organization
Organization Name:INDIAN TERRITORY LONG TERM CARE, INC.
Other - Org Name:INDIAN TERRITORY PROVIDER CARE PLUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAYSON
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:NORTHCUTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-371-2106
Mailing Address - Street 1:105 N NESHOBA ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-1739
Mailing Address - Country:US
Mailing Address - Phone:580-371-0015
Mailing Address - Fax:580-371-3204
Practice Address - Street 1:105 N NESHOBA ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-1739
Practice Address - Country:US
Practice Address - Phone:580-371-0015
Practice Address - Fax:580-371-3204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK100627980B251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100627980BMedicaid