Provider Demographics
NPI:1720515562
Name:MUSCOGEE CREEK NATION
Entity Type:Organization
Organization Name:MUSCOGEE CREEK NATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIETITIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:BREANNA
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:DALE
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD
Authorized Official - Phone:918-224-9310
Mailing Address - Street 1:1125 E CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-4641
Mailing Address - Country:US
Mailing Address - Phone:918-224-9310
Mailing Address - Fax:918-224-3805
Practice Address - Street 1:1125 E CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4641
Practice Address - Country:US
Practice Address - Phone:918-224-9310
Practice Address - Fax:918-224-3805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2157133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty