Provider Demographics
NPI:1063296937
Name:401 MEDICAL CENTER PLLC
Entity type:Organization
Organization Name:401 MEDICAL CENTER PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ APRN
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:E
Authorized Official - Last Name:DENTON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-CNP, FNP-BC
Authorized Official - Phone:918-316-6369
Mailing Address - Street 1:401 E DOWNING ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3015
Mailing Address - Country:US
Mailing Address - Phone:918-316-3764
Mailing Address - Fax:918-398-8982
Practice Address - Street 1:401 E DOWNING ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3015
Practice Address - Country:US
Practice Address - Phone:918-316-3764
Practice Address - Fax:918-398-8982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-22
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1013603232OtherNPI
OK201173250AMedicaid