Provider Demographics
NPI:1750150256
Name:THORNBURG, RICKEY ALLEN JR
Entity type:Individual
Prefix:
First Name:RICKEY
Middle Name:ALLEN
Last Name:THORNBURG
Suffix:JR
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 1:717 BUTLER ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-2400
Mailing Address - Country:US
Mailing Address - Phone:803-996-6955
Mailing Address - Fax:
Practice Address - Street 1:717 BUTLER ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2400
Practice Address - Country:US
Practice Address - Phone:580-399-6955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist