Provider Demographics
NPI:1790776086
Name:HOSPICE CENTER OF SOUTHEASTERN OKLAHOMA, INC
Entity Type:Organization
Organization Name:HOSPICE CENTER OF SOUTHEASTERN OKLAHOMA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-920-0600
Mailing Address - Street 1:PO BOX 1018
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74702-1018
Mailing Address - Country:US
Mailing Address - Phone:580-920-0600
Mailing Address - Fax:580-920-0610
Practice Address - Street 1:1100 NE LINCOLN RD
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-2412
Practice Address - Country:US
Practice Address - Phone:580-208-2273
Practice Address - Fax:580-286-2226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4210251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK371662Medicare Oscar/Certification