Provider Demographics
NPI:1629308341
Name:PETERS AGENCY TRANSITION SERVICES LLC
Entity Type:Organization
Organization Name:PETERS AGENCY TRANSITION SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR, CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TRUDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:RN CCM CPUR
Authorized Official - Phone:918-775-6555
Mailing Address - Street 1:926 E CHEROKEE AVE
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-5045
Mailing Address - Country:US
Mailing Address - Phone:918-775-6555
Mailing Address - Fax:918-775-6587
Practice Address - Street 1:926 E CHEROKEE AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-5045
Practice Address - Country:US
Practice Address - Phone:918-775-6555
Practice Address - Fax:918-775-6587
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PETERS AGENCY CARE MANAGEMENT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-31
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100685560AMedicaid