1760709042 NPI number — EXCEL THERAPY SPECIALISTS, LLC

Table of content: (NPI 1760709042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760709042 NPI number — EXCEL THERAPY SPECIALISTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXCEL THERAPY SPECIALISTS, 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:
1760709042
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2232 W HOUSTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROKEN ARROW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74012-3529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-259-9522
Provider Business Mailing Address Fax Number:
918-259-9521

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
698 WESTSIDE DR
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
DURANT
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74701-3084
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-931-3300
Provider Business Practice Location Address Fax Number:
580-931-3301
Provider Enumeration Date:
04/27/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MINNICK
Authorized Official First Name:
TIM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
918-259-9522

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , 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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