Basic Information
| Provider Information | |||||||||
| NPI: | 1649643180 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXCEL THERAPY SPECIALISTS--OKC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2234-B W HOUSTON | ||||||||
| Address2: | |||||||||
| City: | BROKEN ARROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740123519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182591888 | ||||||||
| FaxNumber: | 9182513725 | ||||||||
| Practice Location | |||||||||
| Address1: | 1742 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730185901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058253617 | ||||||||
| FaxNumber: | 4058253618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2015 | ||||||||
| LastUpdateDate: | 06/30/2016 | ||||||||
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| AuthorizedOfficialLastName: | WAGONER | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9182591888 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200620300A | 05 | OK | MEDICAID |