Healthcare Provider Details

I. General information

NPI: 1699158683
Provider Name (Legal Business Name): WHITE HORSE RANCH OUTPATIENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40803 S COUNTY ROAD 213 1601 WILKIE ROAD
MOORELAND OK
73852-9131
US

IV. Provider business mailing address

40803 S COUNTY ROAD 213 1601 WILKIE ROAD
MOORELAND OK
73852-9131
US

V. Phone/Fax

Practice location:
  • Phone: 580-994-5649
  • Fax: 580-994-5972
Mailing address:
  • Phone: 580-994-5649
  • Fax: 580-994-5972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4974
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number839
License Number StateOK

VIII. Authorized Official

Name: TAMMIE RENEE SMITH
Title or Position: EXECUTIVE DIRECTOR
Credential: LPC, LADC
Phone: 580-571-1272