MEDICARE: DEBERRY INTERPRISE

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1497026173
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEBERRY INTERPRISE

Provider Business Mailing Address
First Line	:	PO BOX 102
Second Line	:
City	:	CHOCTAW
State	:	OK
Zip	:	73020-0102
Country	:	US
Telephone Number	:	405-549-9061
Fax Number	:

Provider Business Practice Location Address
First Line	:	9233 NORTH EAST10TH STREET
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73130
Country	:	US
Telephone Number	:	405-549-9061
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MRS. BARBARA ANN DEBERRY
Credential	:	BACHELOR DEGREE
Telephone Number	:	405-259-8400

Provider Enumeration Date	:	01/26/2012
Last Update Date	:	01/26/2012

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