Organization
UNITED KEETOOWAH BAND COMMUNITY HEALTH INITIATIVE, LLC
Active
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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