Provider Demographics
NPI:1194803346
Name:KICKAPOO TRIBAL HEALTH CENTER
Entity type:Organization
Organization Name:KICKAPOO TRIBAL HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHTAPENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-964-2081
Mailing Address - Street 1:105365 S. HWY 102
Mailing Address - Street 2:BUILDING M
Mailing Address - City:MCLOUD
Mailing Address - State:OK
Mailing Address - Zip Code:74851
Mailing Address - Country:US
Mailing Address - Phone:405-964-2081
Mailing Address - Fax:405-964-7160
Practice Address - Street 1:105365 S. HWY 102
Practice Address - Street 2:BUILDING M
Practice Address - City:MCLOUD
Practice Address - State:OK
Practice Address - Zip Code:74851
Practice Address - Country:US
Practice Address - Phone:405-964-2081
Practice Address - Fax:405-964-7160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK3721809OtherNABP
OK100245200AMedicaid