Provider Demographics
NPI:1104344027
Name:CHOCTAW NATION OF OKLAHOMA
Entity type:Organization
Organization Name:CHOCTAW NATION OF OKLAHOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-567-7000
Mailing Address - Street 1:PO BOX 1577
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74702-1577
Mailing Address - Country:US
Mailing Address - Phone:580-916-9140
Mailing Address - Fax:580-916-9142
Practice Address - Street 1:1 CHOCTAW WAY
Practice Address - Street 2:
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-2022
Practice Address - Country:US
Practice Address - Phone:918-567-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-30
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP0904X
OK261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal