Provider Demographics
NPI:1073335949
Name:TABOR THERAPEUTICS LLC
Entity type:Organization
Organization Name:TABOR THERAPEUTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRACKELIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-250-6639
Mailing Address - Street 1:1001 15TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1803
Mailing Address - Country:US
Mailing Address - Phone:580-798-5105
Mailing Address - Fax:
Practice Address - Street 1:1001 15TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1803
Practice Address - Country:US
Practice Address - Phone:580-798-5015
Practice Address - Fax:580-798-5018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty