MEDICARE: FORT COBB-BROXTON SDI-167

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	251300000X	Local Education Agency (LEA)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518098722
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT COBB-BROXTON SDI-167

Provider Business Mailing Address
First Line	:	PO BOX 130
Second Line	:
City	:	FORT COBB
State	:	OK
Zip	:	73038-0130
Country	:	US
Telephone Number	:	405-643-2336
Fax Number	:	405-643-2547

Provider Business Practice Location Address
First Line	:	600 TOWAKONIE ST
Second Line	:
City	:	FORT COBB
State	:	OK
Zip	:	73038
Country	:	US
Telephone Number	:	405-643-2336
Fax Number	:	405-643-2547

Authorized Official
Title or Position	:	SUPERINTENDENT
Name	:	MR. KYLE W LIERLE
Credential	:
Telephone Number	:	405-643-2336

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	12/19/2011

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