Basic Information
| Provider Information | |||||||||
| NPI: | 1669742813 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BECKER | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | PT,DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 269084 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731269084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233988072 | ||||||||
| FaxNumber: | 6233988235 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 HAMACHER ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | WATERLOO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622981592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189395555 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2012 | ||||||||
| LastUpdateDate: | 01/27/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 9500 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 667736 | 05 | AZ | MEDICAID |