Provider Demographics
NPI:1831182625
Name:COUNTRY STYLE HEALTH CARE INC IV
Entity type:Organization
Organization Name:COUNTRY STYLE HEALTH CARE INC IV
Other - Org Name:
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:918-689-5352
Mailing Address - Street 1:301 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EUFAULA
Mailing Address - State:OK
Mailing Address - Zip Code:74432-3253
Mailing Address - Country:US
Mailing Address - Phone:918-689-5352
Mailing Address - Fax:918-689-9446
Practice Address - Street 1:301 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EUFAULA
Practice Address - State:OK
Practice Address - Zip Code:74432-3253
Practice Address - Country:US
Practice Address - Phone:918-689-5352
Practice Address - Fax:918-689-9446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKHC7647251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100261740HMedicaid
OK100261740FMedicaid
OK100261740JMedicaid
OK100261740CMedicaid
OK100261740BMedicaid
OK100261740GMedicaid
OK100261740IMedicaid
OK100261740KMedicaid
OK100261740LMedicaid
OK100261740LMedicaid
=========OtherTRICARE
OK100261740CMedicaid