1568685865 NPI number — EXCEL PHYSICAL THERAPY INSTITUTE, LLC

Table of content: MRS. KRISTEN JEANELLE PETERSON PT (NPI 1669452629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568685865 NPI number — EXCEL PHYSICAL THERAPY INSTITUTE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXCEL PHYSICAL THERAPY INSTITUTE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568685865
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1212 S AIR DEPOT BLVD
Provider Second Line Business Mailing Address:
SUITE 17
Provider Business Mailing Address City Name:
MIDWEST CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73110-4870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-455-3784
Provider Business Mailing Address Fax Number:
405-455-3844

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1212 S AIR DEPOT BLVD
Provider Second Line Business Practice Location Address:
SUITE 17
Provider Business Practice Location Address City Name:
MIDWEST CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73110-4870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-455-3784
Provider Business Practice Location Address Fax Number:
405-455-3844
Provider Enumeration Date:
04/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WALLACE
Authorized Official First Name:
SHAWN
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER - PARTNER
Authorized Official Telephone Number:
405-455-3784

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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