Basic Information
| Provider Information | |||||||||
| NPI: | 1730251620 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXCEL-ARDMORE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2232 W HOUSTON ST | ||||||||
| Address2: | |||||||||
| City: | BROKEN ARROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740123529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182599522 | ||||||||
| FaxNumber: | 9182599521 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 12TH STREET NW | ||||||||
| Address2: | STE A | ||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802269235 | ||||||||
| FaxNumber: | 5802269239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 02/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | MINNICK | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9182599522 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EXCEL THERAPY SPECIALISTS, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OK | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.