Provider Demographics
NPI:1871764373
Name:JAMES L KNECHT D.O., INC.
Entity type:Organization
Organization Name:JAMES L KNECHT D.O., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:KNECHT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-336-2209
Mailing Address - Street 1:505 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:OK
Mailing Address - Zip Code:73077-5021
Mailing Address - Country:US
Mailing Address - Phone:580-336-2209
Mailing Address - Fax:580-336-4584
Practice Address - Street 1:505 N 14TH ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:OK
Practice Address - Zip Code:73077-5021
Practice Address - Country:US
Practice Address - Phone:580-336-2209
Practice Address - Fax:580-336-4584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2238208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100100500AMedicaid
37D0719246OtherCLIA NUMBER
OK100100500AMedicaid