Provider Demographics
NPI:1730560699
Name:PREMIER PEDIATRIC AND ADOLESCENT CARE
Entity type:Organization
Organization Name:PREMIER PEDIATRIC AND ADOLESCENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOOS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-816-4024
Mailing Address - Street 1:2009 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401
Mailing Address - Country:US
Mailing Address - Phone:918-816-4024
Mailing Address - Fax:918-816-4025
Practice Address - Street 1:2009 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401
Practice Address - Country:US
Practice Address - Phone:918-816-4024
Practice Address - Fax:918-816-4025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center