Provider Demographics
NPI:1679775308
Name:CHOCTAW MANAGEMENT SERVICES ENTERPRISE
Entity Type:Organization
Organization Name:CHOCTAW MANAGEMENT SERVICES ENTERPRISE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-267-3728
Mailing Address - Street 1:2773 MAYFAIR DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-2601
Mailing Address - Country:US
Mailing Address - Phone:248-649-1042
Mailing Address - Fax:
Practice Address - Street 1:1172 KIRTS BLVD
Practice Address - Street 2:U.S. MEPS
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4846
Practice Address - Country:US
Practice Address - Phone:248-244-9131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037778171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Single Specialty