Organization
UNITED KEETOOWAH BAND COMMUNITY HEALTH INITIATIVE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. BRYAN CLARK SHADE MBA (EXECUTIVE DIRECTOR)
(918) 431-1818
Entity
Organization
Contact information
Practice address
2450 S MUSKOGEE AVE, TAHLEQUAH, OK 74464-5450
(918) 431-1818
(918) 431-1873
Mailing address
2450 S MUSKOGEE AVE, TAHLEQUAH, OK 74464-5450
(918) 431-1818
(918) 431-1873
Taxonomy
Speciality
Code
Description
License number
State
305S00000X
Point of Service
Primary
OK4140
OK
Other
Enumeration date
09/11/2012
Last updated
09/11/2012
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