Provider Demographics
NPI:1093163024
Name:ILBOUDO, THIMOTEE
Entity Type:Individual
Prefix:
First Name:THIMOTEE
Middle Name:
Last Name:ILBOUDO
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 1:3198 HIGHWAY 412 STE B206
Mailing Address - Street 2:
Mailing Address - City:COLCORD
Mailing Address - State:OK
Mailing Address - Zip Code:74338-1356
Mailing Address - Country:US
Mailing Address - Phone:479-365-7096
Mailing Address - Fax:
Practice Address - Street 1:3198 HIGHWAY 412 STE B
Practice Address - Street 2:
Practice Address - City:COLCORD
Practice Address - State:OK
Practice Address - Zip Code:74338-1356
Practice Address - Country:US
Practice Address - Phone:479-365-7096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2022-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR343900000X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)