MEDICARE: MRS. ALTIS BEATRICE RUTHERFORD BA,BHRS, CM-A

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1720118276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALTIS BEATRICE RUTHERFORD BA,BHRS, CM-A

Provider Business Mailing Address
First Line	:	PO BOX 673
Second Line	:
City	:	VALLIANT
State	:	OK
Zip	:	74764-0673
Country	:	US
Telephone Number	:	580-933-7031
Fax Number	:	580-933-7034

Provider Business Practice Location Address
First Line	:	300 N DALTON
Second Line	:
City	:	VALLIANT
State	:	OK
Zip	:	74764
Country	:	US
Telephone Number	:	580-286-6638
Fax Number	:	580-286-5206

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

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	09/22/2011

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