Provider Demographics
NPI:1164016192
Name:CAGLE, BRIAN CHARLES
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:CHARLES
Last Name:CAGLE
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 1:1239 S QUINCY AVE APT 16
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-5277
Mailing Address - Country:US
Mailing Address - Phone:918-764-0662
Mailing Address - Fax:
Practice Address - Street 1:1239 S QUINCY AVE APT 16
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-5277
Practice Address - Country:US
Practice Address - Phone:918-764-0662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-20
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility