Provider Demographics
NPI:1912006644
Name:CITY OF CHECOTAH
Entity Type:Organization
Organization Name:CITY OF CHECOTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AMBULANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-473-5411
Mailing Address - Street 1:414 W GENTRY AVE
Mailing Address - Street 2:
Mailing Address - City:CHECOTAH
Mailing Address - State:OK
Mailing Address - Zip Code:74426-2444
Mailing Address - Country:US
Mailing Address - Phone:800-538-8278
Mailing Address - Fax:580-628-2273
Practice Address - Street 1:414 W GENTRY AVE
Practice Address - Street 2:
Practice Address - City:CHECOTAH
Practice Address - State:OK
Practice Address - Zip Code:74426-2444
Practice Address - Country:US
Practice Address - Phone:800-538-8278
Practice Address - Fax:580-628-2273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKEMS1743416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK590120561OtherRRMC PROVIDER NUMBER
OK100819660AMedicaid
OK590120561OtherRRMC PROVIDER NUMBER
OK100819660AMedicaid