Healthcare Provider Details

I. General information

NPI: 1295934339
Provider Name (Legal Business Name): PRAGUE PUBLIC SCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3504 NBU
PRAGUE OK
74864-2031
US

IV. Provider business mailing address

3504 NBU
PRAGUE OK
74864-2031
US

V. Phone/Fax

Practice location:
  • Phone: 405-567-4455
  • Fax: 405-567-3095
Mailing address:
  • Phone: 405-567-4455
  • Fax: 405-567-3095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number255K00000X
License Number StateOK

VIII. Authorized Official

Name: MR. RICKY DALE MARTIN
Title or Position: SUPERINTENDENT
Credential:
Phone: 405-567-4455