Provider Demographics
NPI:1134250731
Name:HELEN FARRIS
Entity type:Organization
Organization Name:HELEN FARRIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-456-0704
Mailing Address - Street 1:PO BOX 807
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-0807
Mailing Address - Country:US
Mailing Address - Phone:918-456-0704
Mailing Address - Fax:
Practice Address - Street 1:17963 S 543 ROAD
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464
Practice Address - Country:US
Practice Address - Phone:918-456-8677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRC-1101-11013104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKRC-1101-1101OtherSTATE LICENSE