Healthcare Provider Details

I. General information

NPI: 1093163024
Provider Name (Legal Business Name): THIMOTEE ILBOUDO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2016
Last Update Date: 07/04/2022
Certification Date: 07/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3198 HIGHWAY 412 STE B
COLCORD OK
74338-1356
US

IV. Provider business mailing address

3198 HIGHWAY 412 STE B206
COLCORD OK
74338-1356
US

V. Phone/Fax

Practice location:
  • Phone: 479-365-7096
  • Fax:
Mailing address:
  • Phone: 479-365-7096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: