MEDICARE: THIMOTEE ILBOUDO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)		AR
2	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1093163024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THIMOTEE ILBOUDO

Provider Business Mailing Address
First Line	:	3198 HIGHWAY 412 STE B206
Second Line	:
City	:	COLCORD
State	:	OK
Zip	:	74338-1356
Country	:	US
Telephone Number	:	479-365-7096
Fax Number	:

Provider Business Practice Location Address
First Line	:	3198 HIGHWAY 412 STE B
Second Line	:
City	:	COLCORD
State	:	OK
Zip	:	74338-1356
Country	:	US
Telephone Number	:	479-365-7096
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2016
Last Update Date	:	07/04/2022

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Directions to “ THIMOTEE ILBOUDO ” Practice Location

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