Provider Demographics
NPI:1518021286
Name:SEQUELCARE OF OKLAHOMA, LLC
Entity Type:Organization
Organization Name:SEQUELCARE OF OKLAHOMA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC DIR
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:METCALF
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW, LADC
Authorized Official - Phone:580-298-2830
Mailing Address - Street 1:PO BOX 1030
Mailing Address - Street 2:
Mailing Address - City:ANTLERS
Mailing Address - State:OK
Mailing Address - Zip Code:74523-1030
Mailing Address - Country:US
Mailing Address - Phone:580-298-2830
Mailing Address - Fax:580-298-6723
Practice Address - Street 1:103 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-4700
Practice Address - Country:US
Practice Address - Phone:580-920-9056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100744370EMedicaid