Basic Information
| Provider Information | |||||||||
| NPI: | 1336498864 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMC OF OKLAHOMA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2615 CENTENNIAL BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323080586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506561837 | ||||||||
| FaxNumber: | 8508772917 | ||||||||
| Practice Location | |||||||||
| Address1: | 1105 MICHELIN RD | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734011085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802244446 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2012 | ||||||||
| LastUpdateDate: | 04/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | ATKINSON | ||||||||
| AuthorizedOfficialFirstName: | TARA | ||||||||
| AuthorizedOfficialMiddleName: | NICOLE | ||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE & BILLING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 8506561837 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4626 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.