Provider Demographics
NPI:1225356660
Name:RICKEY, CHARLES VERNON (BS/CM II)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:VERNON
Last Name:RICKEY
Suffix:
Gender:M
Credentials:BS/CM II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 332
Mailing Address - Street 2:
Mailing Address - City:WATTS
Mailing Address - State:OK
Mailing Address - Zip Code:74964-0332
Mailing Address - Country:US
Mailing Address - Phone:918-422-4888
Mailing Address - Fax:918-422-5779
Practice Address - Street 1:202 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:WATTS
Practice Address - State:OK
Practice Address - Zip Code:74964-0332
Practice Address - Country:US
Practice Address - Phone:918-422-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-10
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator