Healthcare Provider Details

I. General information

NPI: 1932724879
Provider Name (Legal Business Name): TANNER BLAKE SEFCIK BS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2020
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 E COURT ST
ATOKA OK
74525-2047
US

IV. Provider business mailing address

878 S MONTANA AVE
ATOKA OK
74525-3332
US

V. Phone/Fax

Practice location:
  • Phone: 580-889-5555
  • Fax:
Mailing address:
  • Phone: 580-509-9037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: