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General NPI Number Information
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NPI Number | 1093163024
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Entity Type | Individual
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Provider Name | THIMOTEE ILBOUDO
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Gender | Male
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Dates
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Enumeration Date | 05/31/2016
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Last Update Date | 07/04/2022
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Provider Practice Location Address
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Address Line | 3198 HIGHWAY 412 STE B
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City | COLCORD
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State | OK
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Zip | 74338-1356
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Country | US
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Telephone | 479-365-7096
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Fax |
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Provider Business Mailing Address
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Address Line | 3198 HIGHWAY 412 STE B206
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City | COLCORD
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State | OK
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Zip | 74338-1356
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Country | US
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Telephone | 479-365-7096
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number |
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number |
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License Number State |
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