Provider Demographics
NPI:1619160579
Name:MATTINGLY, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:MATTINGLY
Suffix:
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:PO BOX 686
Mailing Address - Street 2:
Mailing Address - City:ANTLERS
Mailing Address - State:OK
Mailing Address - Zip Code:74523-0686
Mailing Address - Country:US
Mailing Address - Phone:580-298-0200
Mailing Address - Fax:
Practice Address - Street 1:HC 83 BOX 905
Practice Address - Street 2:
Practice Address - City:ANTLERS
Practice Address - State:OK
Practice Address - Zip Code:74523-9428
Practice Address - Country:US
Practice Address - Phone:580-298-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator