Provider Demographics
NPI:1144661240
Name:RUTH, ETHAN
Entity type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:
Last Name:RUTH
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 1:356 PEBBLE LN
Mailing Address - Street 2:
Mailing Address - City:RATLIFF CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73481-8058
Mailing Address - Country:US
Mailing Address - Phone:580-465-0164
Mailing Address - Fax:
Practice Address - Street 1:356 PEBBLE LN
Practice Address - Street 2:
Practice Address - City:RATLIFF CITY
Practice Address - State:OK
Practice Address - Zip Code:73481-8058
Practice Address - Country:US
Practice Address - Phone:580-465-0164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator