Provider Demographics
NPI:1891763843
Name:PETERS AGENCY HOME HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:PETERS AGENCY HOME HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER / OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TRUDY
Authorized Official - Middle Name:ALES
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MBA CCRN CCM LHC
Authorized Official - Phone:918-790-7555
Mailing Address - Street 1:1015 E CHOCTAW AVE
Mailing Address - Street 2:P. O. BOX 886
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-5011
Mailing Address - Country:US
Mailing Address - Phone:918-790-7555
Mailing Address - Fax:918-790-7587
Practice Address - Street 1:1015 E CHOCTAW AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-5011
Practice Address - Country:US
Practice Address - Phone:918-790-7555
Practice Address - Fax:918-790-7587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7822251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK7822OtherLICENSE
OK200104000AMedicaid
OK1891763843OtherNPI
OK200104000AMedicaid