Provider Demographics
NPI:1891949392
Name:GRAND GATEWAY ECONOMIC DEVELOPMENT ASSOCIATION
Entity type:Organization
Organization Name:GRAND GATEWAY ECONOMIC DEVELOPMENT ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERRIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLOCKER
Authorized Official - Suffix:
Authorized Official - Credentials:BSBA
Authorized Official - Phone:918-783-5761
Mailing Address - Street 1:PO BOX B
Mailing Address - Street 2:
Mailing Address - City:BIG CABIN
Mailing Address - State:OK
Mailing Address - Zip Code:74332-0502
Mailing Address - Country:US
Mailing Address - Phone:918-783-5761
Mailing Address - Fax:918-783-5798
Practice Address - Street 1:333 SOUTH OAK STREET
Practice Address - Street 2:
Practice Address - City:BIG CABIN
Practice Address - State:OK
Practice Address - Zip Code:74332-0502
Practice Address - Country:US
Practice Address - Phone:918-783-5761
Practice Address - Fax:918-783-5829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK100679410D251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100679410DMedicaid