Provider Demographics
NPI:1942575956
Name:STATE OF OKLAHOMA-OKMULGEE
Entity Type:Organization
Organization Name:STATE OF OKLAHOMA-OKMULGEE
Other - Org Name:OSUIT STUDENT HEALTH CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF FINANCIAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:9185-611-8322
Mailing Address - Street 1:1801 E 4TH ST
Mailing Address - Street 2:STUDENT UNION BUILDING
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-3942
Mailing Address - Country:US
Mailing Address - Phone:918-293-4946
Mailing Address - Fax:
Practice Address - Street 1:1801 E 4TH ST
Practice Address - Street 2:STUDENT UNION BUILDING
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-3942
Practice Address - Country:US
Practice Address - Phone:918-293-4946
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service