Basic Information
Provider Information | |||||||||
NPI: | 1093131328 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHEASTERN OKLAHOMA FAMILY SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1710 | ||||||||
Address2: |   | ||||||||
City: | KINGSTON | ||||||||
State: | OK | ||||||||
PostalCode: | 734391710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5807459610 | ||||||||
FaxNumber: | 5807459891 | ||||||||
Practice Location | |||||||||
Address1: | 127 NORTH 3RD AVENUE | ||||||||
Address2: |   | ||||||||
City: | DURANT | ||||||||
State: | OK | ||||||||
PostalCode: | 747010000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5809313008 | ||||||||
FaxNumber: | 5809318022 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/11/2014 | ||||||||
LastUpdateDate: | 03/11/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MURPHY | ||||||||
AuthorizedOfficialFirstName: | SHARON | ||||||||
AuthorizedOfficialMiddleName: | RENE | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF ADMINISTRATIVE | ||||||||
AuthorizedOfficialTelephone: | 5807459610 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 100708380 | 05 | OK |   | MEDICAID |