Provider Demographics
NPI:1871843144
Name:UNITED KEETOOWAH BAND OF CHEROKEE INDIANS
Entity Type:Organization
Organization Name:UNITED KEETOOWAH BAND OF CHEROKEE INDIANS
Other - Org Name:UNITED KEETOOWAH BAND COMMUNITY HEALTH INITIATIVE
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-822-1946
Mailing Address - Street 1:PO BOX 746
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465
Mailing Address - Country:US
Mailing Address - Phone:918-822-1946
Mailing Address - Fax:918-431-1873
Practice Address - Street 1:18263 W KEETOOWAH CIRCLE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464
Practice Address - Country:US
Practice Address - Phone:918-822-1946
Practice Address - Fax:918-431-1873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty