Provider Demographics
NPI:1154692572
Name:RITCHIE, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:RITCHIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 4 BOX 2270
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74960-9495
Mailing Address - Country:US
Mailing Address - Phone:918-797-5478
Mailing Address - Fax:918-696-5874
Practice Address - Street 1:RR 4 BOX 2270
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960-9495
Practice Address - Country:US
Practice Address - Phone:918-797-5478
Practice Address - Fax:918-696-5874
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor