Provider Demographics
NPI:1619374337
Name:HIS ARMS EXTENDED
Entity Type:Organization
Organization Name:HIS ARMS EXTENDED
Other - Org Name:HIS ARMS EXTENDED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REVEREND
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:KITE
Authorized Official - Suffix:
Authorized Official - Credentials:REVEREND
Authorized Official - Phone:405-505-8329
Mailing Address - Street 1:2358 COUNTY ROAD 1325
Mailing Address - Street 2:
Mailing Address - City:BLANCHARD
Mailing Address - State:OK
Mailing Address - Zip Code:73010-3522
Mailing Address - Country:US
Mailing Address - Phone:405-505-8329
Mailing Address - Fax:
Practice Address - Street 1:2358 COUNTY ROAD 1325
Practice Address - Street 2:
Practice Address - City:BLANCHARD
Practice Address - State:OK
Practice Address - Zip Code:73010-3522
Practice Address - Country:US
Practice Address - Phone:405-505-8329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service