Provider Demographics
NPI:1609972058
Name:STATE OF OKLAHOMA
Entity Type:Organization
Organization Name:STATE OF OKLAHOMA
Other - Org Name:D/B/A J D MCCARTY CENTER FOR CHILDREN WITH DEVELOPMENTAL DISABILITIES
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR AND CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUESTERSTEFFEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-307-2817
Mailing Address - Street 1:2002 E ROBINSON ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-7420
Mailing Address - Country:US
Mailing Address - Phone:405-307-2800
Mailing Address - Fax:405-307-2801
Practice Address - Street 1:2002 E ROBINSON ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-7420
Practice Address - Country:US
Practice Address - Phone:405-307-2800
Practice Address - Fax:405-307-2801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2239261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100708750AMedicaid
OK100700670AMedicaid
OK100708750AMedicaid