Provider Demographics
NPI:1558740837
Name:LEFLORE COUNTY HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:LEFLORE COUNTY HOSPITAL AUTHORITY
Other - Org Name:HEAVENER MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTITIVE OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, FACHE
Authorized Official - Phone:918-635-3441
Mailing Address - Street 1:PO BOX 689
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-0689
Mailing Address - Country:US
Mailing Address - Phone:918-653-2918
Mailing Address - Fax:918-652-3211
Practice Address - Street 1:304 HIGHWAY 59 N
Practice Address - Street 2:
Practice Address - City:HEAVENER
Practice Address - State:OK
Practice Address - Zip Code:74937-2255
Practice Address - Country:US
Practice Address - Phone:918-653-2918
Practice Address - Fax:918-653-3211
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEFLORE COUNTY HOSPITAL AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-20
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK373480261QR1300X
OKRO028587363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100700730IMedicaid
OK700522186Medicare PIN