Healthcare Provider Details

I. General information

NPI: 1154520856
Provider Name (Legal Business Name): WHITE HORSE RANCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 WILKIE RD
MOORELAND OK
73852-8921
US

IV. Provider business mailing address

1601 WILKIE RD
MOORELAND OK
73852-8921
US

V. Phone/Fax

Practice location:
  • Phone: 580-994-5649
  • Fax: 580-994-2739
Mailing address:
  • Phone: 580-994-5649
  • Fax: 580-994-2739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number StateOK

VIII. Authorized Official

Name: MRS. TAMMIE SMITH
Title or Position: DIRECTOR
Credential:
Phone: 580-994-5649