1205870128 NPI number — MOLLY ELLEN MANUEL DPT

Table of content: MOLLY ELLEN MANUEL DPT (NPI 1205870128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205870128 NPI number — MOLLY ELLEN MANUEL DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANUEL
Provider First Name:
MOLLY
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
MOLLY
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205870128
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2234 W HOUSTON ST STE B
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:
74012-3519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-259-1888
Provider Business Mailing Address Fax Number:
918-251-3725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1742 S 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICKASHA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73018-5901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-825-3617
Provider Business Practice Location Address Fax Number:
405-825-3618
Provider Enumeration Date:
06/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  3665 , 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)

  • Identifier: 200533540A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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