Provider Demographics
NPI:1811998164
Name:COUNTRY STYLE HEALTH CARE INC
Entity type:Organization
Organization Name:COUNTRY STYLE HEALTH CARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BROWNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-465-2626
Mailing Address - Street 1:PO BOX 299
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:OK
Mailing Address - Zip Code:74349-0299
Mailing Address - Country:US
Mailing Address - Phone:918-782-4449
Mailing Address - Fax:918-782-4649
Practice Address - Street 1:156 SOUTH EL PASO Y
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:OK
Practice Address - Zip Code:74349-0299
Practice Address - Country:US
Practice Address - Phone:918-782-4449
Practice Address - Fax:918-782-4649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKHC7371251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100261910AMedicaid
OK100686310BMedicaid
OK100686310BMedicaid