Provider Demographics
NPI:1912781584
Name:RAINES, TINA KEY (LLC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:KEY
Last Name:RAINES
Suffix:
Gender:F
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-5217
Mailing Address - Country:US
Mailing Address - Phone:918-429-8093
Mailing Address - Fax:
Practice Address - Street 1:903 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-5217
Practice Address - Country:US
Practice Address - Phone:918-429-8093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK191225225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist