Provider Demographics
NPI:1487726170
Name:PROVIDENCE SERVICE CORPORATION OF OKLAHOMA
Entity type:Organization
Organization Name:PROVIDENCE SERVICE CORPORATION OF OKLAHOMA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:DUGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-747-6600
Mailing Address - Street 1:620 N CRAYCROFT RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-1448
Mailing Address - Country:US
Mailing Address - Phone:520-747-6600
Mailing Address - Fax:
Practice Address - Street 1:931 ARLINGTON ST STE 2
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4025
Practice Address - Country:US
Practice Address - Phone:580-332-6851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========001OtherBCBS
OK=========004OtherTRICARE