Basic Information
Provider Information
NPI: 1568759587
EntityType: 2
ReplacementNPI:  
OrganizationName: SUPPLEMENTAL HEALTHCARE
LastName:  
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Mailing Information
Address1: 3030 NW EXPRESSWAY
Address2: SUITE #809
City: OKLAHOMA CITY
State: OK
PostalCode: 731125474
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 3030 NW EXPRESSWAY
Address2: SUITE #809
City: OKLAHOMA CITY
State: OK
PostalCode: 731125474
CountryCode: US
TelephoneNumber: 4059177160
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/29/2011
LastUpdateDate: 06/29/2011
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: WHITLEY
AuthorizedOfficialFirstName: AJ
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AuthorizedOfficialTitleorPosition: STAFFING MANAGER
AuthorizedOfficialTelephone: 4059177160
IsSoleProprietor:  
IsOrganizationSubpart: N
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NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
235Z00000X3524OKY193400000X SINGLE SPECIALTY GROUPSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist 

No ID Information.


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