Provider Demographics
NPI:1790008902
Name:PROVIDENCE OF OKLAHOMA
Entity Type:Organization
Organization Name:PROVIDENCE OF OKLAHOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSRS
Authorized Official - Prefix:
Authorized Official - First Name:ANNJAVETTA
Authorized Official - Middle Name:D
Authorized Official - Last Name:BABB
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:580-326-7477
Mailing Address - Street 1:117 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743-6237
Mailing Address - Country:US
Mailing Address - Phone:580-326-7477
Mailing Address - Fax:580-326-6400
Practice Address - Street 1:117 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-6237
Practice Address - Country:US
Practice Address - Phone:580-326-7477
Practice Address - Fax:580-326-6400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health