Healthcare Provider Details

I. General information

NPI: 1629351846
Provider Name (Legal Business Name): THACKERVILLE PUBLIC SCHOOLS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2011
Last Update Date: 09/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 77 AND HWY 153
THACKERVILLE OK
73459-0377
US

IV. Provider business mailing address

PO BOX 377
THACKERVILLE OK
73459-0377
US

V. Phone/Fax

Practice location:
  • Phone: 580-276-2630
  • Fax: 580-276-2638
Mailing address:
  • Phone: 580-276-2630
  • Fax: 580-276-2638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GRACIE RAINS
Title or Position: MEDICAID COORDINATOR
Credential:
Phone: 580-276-2630