Provider Demographics
NPI:1568976991
Name:ARKANSAS VERDIGRIS VALLEY HEALTH CENTERS,INC.
Entity Type:Organization
Organization Name:ARKANSAS VERDIGRIS VALLEY HEALTH CENTERS,INC.
Other - Org Name:MUSKOGEE HEALTH CENTER WEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:QI
Authorized Official - Prefix:MR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:DEON
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-483-0111
Mailing Address - Street 1:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:OK
Mailing Address - Zip Code:74454-0334
Mailing Address - Country:US
Mailing Address - Phone:918-483-0111
Mailing Address - Fax:
Practice Address - Street 1:201 NORTH 32ND STREET
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-2104
Practice Address - Country:US
Practice Address - Phone:918-912-2333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-21
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK207Q00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty