Basic Information
| Provider Information | |||||||||
| NPI: | 1942284021 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 511 WINDSOR DR | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740746962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057070900 | ||||||||
| FaxNumber: | 4057073363 | ||||||||
| Practice Location | |||||||||
| Address1: | 511 WINDSOR DR | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740746962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057070900 | ||||||||
| FaxNumber: | 4057073363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 08/13/2008 | ||||||||
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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 | 2251X0800X | 3091 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 200069230A | 05 | OK | MEDICAID |