Provider Demographics
NPI:1265518203
Name:KICKAPOO TRIBAL HEALTH CENTER
Entity type:Organization
Organization Name:KICKAPOO TRIBAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JANETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHTAPENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-964-2081
Mailing Address - Street 1:PO BOX 1360
Mailing Address - Street 2:
Mailing Address - City:MCLOUD
Mailing Address - State:OK
Mailing Address - Zip Code:74851-1360
Mailing Address - Country:US
Mailing Address - Phone:405-964-2081
Mailing Address - Fax:405-964-2053
Practice Address - Street 1:105365 S. HWY 102
Practice Address - Street 2:BUILDING M
Practice Address - City:MCLOUD
Practice Address - State:OK
Practice Address - Zip Code:74851
Practice Address - Country:US
Practice Address - Phone:405-964-2081
Practice Address - Fax:405-964-2053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100700140AMedicaid
WI371826Medicare Oscar/Certification