Provider Demographics
NPI:1871039396
Name:NORTHERN OKLAHOMA ADDICTION CLINIC
Entity Type:Organization
Organization Name:NORTHERN OKLAHOMA ADDICTION CLINIC
Other - Org Name:NOAC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER CONTACT
Authorized Official - Prefix:
Authorized Official - First Name:ALEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKSHEAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-645-9999
Mailing Address - Street 1:304 BOULDER ST
Mailing Address - Street 2:
Mailing Address - City:PAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74058-4028
Mailing Address - Country:US
Mailing Address - Phone:918-762-3663
Mailing Address - Fax:918-762-2544
Practice Address - Street 1:304 BOULDER ST
Practice Address - Street 2:
Practice Address - City:PAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74058-4028
Practice Address - Country:US
Practice Address - Phone:918-762-3663
Practice Address - Fax:918-762-2544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-08
Last Update Date:2017-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1532261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain