Provider Demographics
NPI:1962752659
Name:UNITED KEETOOWAH BAND COMMUNITY HEALTH INITIATIVE, LLC
Entity type:Organization
Organization Name:UNITED KEETOOWAH BAND COMMUNITY HEALTH INITIATIVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:SHADE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:918-431-1818
Mailing Address - Street 1:2450 S MUSKOGEE AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-5450
Mailing Address - Country:US
Mailing Address - Phone:918-431-1818
Mailing Address - Fax:918-431-1873
Practice Address - Street 1:2450 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5450
Practice Address - Country:US
Practice Address - Phone:918-431-1818
Practice Address - Fax:918-431-1873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK4140305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service