Basic Information
Provider Information | |||||||||
NPI: | 1891919130 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EXCEL THERAPY SPECIALISTS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2232 W HOUSTON ST | ||||||||
Address2: |   | ||||||||
City: | BROKEN ARROW | ||||||||
State: | OK | ||||||||
PostalCode: | 740123529 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9182599522 | ||||||||
FaxNumber: | 9182599521 | ||||||||
Practice Location | |||||||||
Address1: | 523 E 6TH ST | ||||||||
Address2: |   | ||||||||
City: | OKMULGEE | ||||||||
State: | OK | ||||||||
PostalCode: | 744475520 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9187566060 | ||||||||
FaxNumber: | 9187566058 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2007 | ||||||||
LastUpdateDate: | 08/31/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MINNICK | ||||||||
AuthorizedOfficialFirstName: | TIM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9182599522 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.