Provider Demographics
NPI:1427090851
Name:HOLDENVILLE HOME HEALTH, LLC
Entity type:Organization
Organization Name:HOLDENVILLE HOME HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MATHIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-379-2300
Mailing Address - Street 1:711 N BULLITT ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:HOLDENVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74848-3804
Mailing Address - Country:US
Mailing Address - Phone:405-379-2300
Mailing Address - Fax:405-379-2309
Practice Address - Street 1:711 N BULLITT ST
Practice Address - Street 2:SUITE B
Practice Address - City:HOLDENVILLE
Practice Address - State:OK
Practice Address - Zip Code:74848-3804
Practice Address - Country:US
Practice Address - Phone:405-379-2300
Practice Address - Fax:405-379-2309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK377448251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100699880DMedicaid
OK000377448001OtherBC/BS #
OK100699880DMedicaid