Provider Demographics
NPI:1720175292
Name:MEDIC-AIRE OF TAHLEQUAH, INC.
Entity Type:Organization
Organization Name:MEDIC-AIRE OF TAHLEQUAH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:T
Authorized Official - Last Name:HISELEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-453-9991
Mailing Address - Street 1:17900 S MUSKOGEE AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-5494
Mailing Address - Country:US
Mailing Address - Phone:918-453-9991
Mailing Address - Fax:
Practice Address - Street 1:17900 MUSKOGEE AVENUE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5494
Practice Address - Country:US
Practice Address - Phone:918-453-9991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKN/A332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5858280001Medicare NSC