Basic Information
| Provider Information | |||||||||
| NPI: | 1285136135 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHEPHERD MALL THERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4334 NW EXPRESSWAY STE 187 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731161515 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 4052124270 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 NW 23RD ST STE 2D | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731072420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053553239 | ||||||||
| FaxNumber: | 4052124270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2018 | ||||||||
| LastUpdateDate: | 03/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | EDWIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4053553239 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0700X | N | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech | 261QX0100X | N | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.