Basic Information
| Provider Information | |||||||||
| NPI: | 1730502279 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RURAK | ||||||||
| FirstName: | JACKIE (JACK) | ||||||||
| MiddleName: | DUWAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ATP #64040 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 604 N NOLAN RIVER RD | ||||||||
| Address2: | |||||||||
| City: | CLEBURNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760337008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176454718 | ||||||||
| FaxNumber: | 8176412960 | ||||||||
| Practice Location | |||||||||
| Address1: | 604 N NOLAN RIVER RD | ||||||||
| Address2: | |||||||||
| City: | CLEBURNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760337008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176454718 | ||||||||
| FaxNumber: | 8176412960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2014 | ||||||||
| LastUpdateDate: | 02/03/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | TX | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
ID Information
| ID | Type | State | Issuer | Description | 015900601 | 05 | TX | MEDICAID |