=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063769867
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STIDHAM SCHOOL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2012
-----------------------------------------------------
Last Update Date | 08/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1ST AND MAIN
-----------------------------------------------------
City | STIDHAM
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-689-5241
-----------------------------------------------------
Fax | 918-689-9163
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | HC 64 BOX 2110
-----------------------------------------------------
City | EUSALA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-689-5241
-----------------------------------------------------
Fax | 918-689-9163
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERINTENDENT
-----------------------------------------------------
Name | BART BANFIELD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 918-689-5241
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------