Provider Demographics
NPI:1942754510
Name:JEFFERSON COUNTY HEALTHCARE AUTHORITY
Entity Type:Organization
Organization Name:JEFFERSON COUNTY HEALTHCARE AUTHORITY
Other - Org Name:WAURIKA FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLESPIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-228-2344
Mailing Address - Street 1:9172 US HWY 70
Mailing Address - Street 2:INTERSECTION HWYS 70&81
Mailing Address - City:WAURIKA
Mailing Address - State:OK
Mailing Address - Zip Code:73573-0090
Mailing Address - Country:US
Mailing Address - Phone:580-228-3669
Mailing Address - Fax:580-228-2529
Practice Address - Street 1:9172 US HWY 70
Practice Address - Street 2:INTERSECTION HWYS 70 & 81
Practice Address - City:WAURIKA
Practice Address - State:OK
Practice Address - Zip Code:73573-0090
Practice Address - Country:US
Practice Address - Phone:580-228-3669
Practice Address - Fax:580-228-2529
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFERSON COUNTY HEALTHCARE AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-11
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK900522039OtherMEDICARE PTAN
OK100730660FMedicaid