Provider Demographics
NPI:1245450444
Name:CANADIAN COUNTY
Entity type:Organization
Organization Name:CANADIAN COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILITY DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTH
Authorized Official - Suffix:
Authorized Official - Credentials:LBP
Authorized Official - Phone:405-262-0202
Mailing Address - Street 1:7905 EAST HIGHWAY 66
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036
Mailing Address - Country:US
Mailing Address - Phone:405-262-0202
Mailing Address - Fax:405-262-0259
Practice Address - Street 1:7905 EAST HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036
Practice Address - Country:US
Practice Address - Phone:405-262-0202
Practice Address - Fax:405-262-0259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKK850000246261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2000727780Medicaid