Provider Demographics
NPI:1770544769
Name:STATE OF OKLAHOMA
Entity type:Organization
Organization Name:STATE OF OKLAHOMA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:CO,PLO,BOCOC,CPED
Authorized Official - Phone:918-293-5155
Mailing Address - Street 1:PO BOX 2506
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-8501
Mailing Address - Country:US
Mailing Address - Phone:918-293-5155
Mailing Address - Fax:918-293-5407
Practice Address - Street 1:1801 E 4TH ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-3942
Practice Address - Country:US
Practice Address - Phone:918-293-5155
Practice Address - Fax:918-293-5407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3335E00000X, 332BC3200X
OK13335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered335E00000XSuppliersProsthetic/Orthotic Supplier
Not Answered332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKNO NUMBER TO DATEOtherCOMMUNITY CARE HEALTH
OKNO NUMBEROtherLIMBS FOR LIFE
OKNO NUMBEROtherOKLAHOMA REHAB.
OKNO NUMBER TO DATEOtherCREEK NATION
OKNO NUMBER TO DATEOtherVETERANS ADMIN. HOSP.
OKNO NUMBEROtherLIMBS FOR LIFE
OK=========-058OtherBCBS PROVIDER NUMBER