Provider Demographics
NPI:1700807997
Name:INTEGRIS BASS BAPTIST HEALTH CENTER
Entity type:Organization
Organization Name:INTEGRIS BASS BAPTIST HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-359-4890
Mailing Address - Street 1:PO BOX 200731
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-0731
Mailing Address - Country:US
Mailing Address - Phone:405-252-8319
Mailing Address - Fax:
Practice Address - Street 1:401 S 3RD ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5737
Practice Address - Country:US
Practice Address - Phone:580-548-1116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2244251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100699500HMedicaid
OK377208Medicare Oscar/Certification