Provider Demographics
NPI:1124317680
Name:I.D.
Entity type:Organization
Organization Name:I.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:COMBS
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:405-243-4252
Mailing Address - Street 1:1330 N CLASSEN BLVD
Mailing Address - Street 2:SUITE 313
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-6835
Mailing Address - Country:US
Mailing Address - Phone:405-243-4252
Mailing Address - Fax:
Practice Address - Street 1:1330 N CLASSEN BLVD
Practice Address - Street 2:SUITE 313
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-6835
Practice Address - Country:US
Practice Address - Phone:405-243-4252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health