Provider Demographics
NPI:1932724879
Name:SEFCIK, TANNER BLAKE (BS)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:BLAKE
Last Name:SEFCIK
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:878 S MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-3332
Mailing Address - Country:US
Mailing Address - Phone:580-509-9037
Mailing Address - Fax:
Practice Address - Street 1:321 E COURT ST
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-2047
Practice Address - Country:US
Practice Address - Phone:580-889-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator