Provider Demographics
NPI:1689664195
Name:WEWOKA INDIAN HEALTH
Entity Type:Organization
Organization Name:WEWOKA INDIAN HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:FARREL
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-257-6282
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:WEWOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74884-1475
Mailing Address - Country:US
Mailing Address - Phone:405-257-7318
Mailing Address - Fax:405-257-2696
Practice Address - Street 1:36640 HWY 270
Practice Address - Street 2:
Practice Address - City:WEWOKA
Practice Address - State:OK
Practice Address - Zip Code:74884
Practice Address - Country:US
Practice Address - Phone:405-257-6282
Practice Address - Fax:405-257-2696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100689220AMedicaid