Provider Demographics
NPI:1124156807
Name:COUNTY OF MAYES LOCUST GROVE SCHOOLS
Entity type:Organization
Organization Name:COUNTY OF MAYES LOCUST GROVE SCHOOLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BILLIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-479-5243
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:419 NORTH BROADWAY
Mailing Address - City:LOCUST GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74352
Mailing Address - Country:US
Mailing Address - Phone:918-479-5243
Mailing Address - Fax:918-479-6468
Practice Address - Street 1:700 NORTH HIGHWAY 82
Practice Address - Street 2:LOCUST GROVE MIDDLE SCHOOL
Practice Address - City:LOCUST GROVE
Practice Address - State:OK
Practice Address - Zip Code:74352
Practice Address - Country:US
Practice Address - Phone:918-479-5317
Practice Address - Fax:918-479-5347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100687900AMedicaid