Basic Information
| Provider Information | |||||||||
| NPI: | 1487248597 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIDDLE | ||||||||
| FirstName: | MALORI | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 372 | ||||||||
| Address2: | |||||||||
| City: | BOSWELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747270372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186497989 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1088 S GIN RD | ||||||||
| Address2: | |||||||||
| City: | ATOKA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745257378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805095041 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2021 | ||||||||
| LastUpdateDate: | 03/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | OK | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.