| Full Name | |
|---|---|
| Speciality | Counselor |
| Location | 58150 E 66 Rd, Miami, Oklahoma |
| Authorized Official Name and Position | Jacob Ronald White (DIRECTOR, QCS) |
| Authorized Official Contact | 9185421786 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 876 Miami OK 74355-0876 Ph: (918) 542-1853 | 58150 E 66 Rd Miami OK 74354-6509 Ph: (918) 542-1786 |
| NPI Number | 1457311458 |
|---|---|
| Provider Enumeration Date | 03/24/2006 |
| Last Update Date | 01/23/2020 |
| Certification Date | 01/23/2020 |
| Medicare PECOS PAC ID | 4789734476 |
|---|---|
| Medicare Enrollment ID | O20200416000656 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1457311458 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YA0400X | Counselor - Addiction (substance Use Disorder) | (Oklahoma) | Primary |
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