Provider Demographics
NPI:1013277979
Name:HEARTLAND TRAVEL HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:HEARTLAND TRAVEL HEALTH SERVICES LLC
Other - Org Name:PASSPORT HEALTH OF OKLAHOMA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRET
Authorized Official - Middle Name:RICE
Authorized Official - Last Name:HAYMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-563-8961
Mailing Address - Street 1:3545 NW 58TH ST
Mailing Address - Street 2:SUIT 340
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4726
Mailing Address - Country:US
Mailing Address - Phone:888-528-9521
Mailing Address - Fax:888-521-6702
Practice Address - Street 1:3545 NW 58TH ST
Practice Address - Street 2:SUIT 340
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4726
Practice Address - Country:US
Practice Address - Phone:888-528-9521
Practice Address - Fax:888-521-6702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-24
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK28286302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization