Provider Demographics
NPI:1497941439
Name:RUTHERFORD, LONNIE DOUGLAS (LADC)
Entity Type:Individual
Prefix:MR
First Name:LONNIE
Middle Name:DOUGLAS
Last Name:RUTHERFORD
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 E FIR ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:OK
Mailing Address - Zip Code:73077-4900
Mailing Address - Country:US
Mailing Address - Phone:580-762-7561
Mailing Address - Fax:580-762-2576
Practice Address - Street 1:102 E FIR ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:OK
Practice Address - Zip Code:73077-4900
Practice Address - Country:US
Practice Address - Phone:580-762-7561
Practice Address - Fax:580-762-2576
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK323171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator