MEDICARE: EXCEL THERAPY SPECIALISTS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist		OK

General Provider Information

NPI Number	:	1275691651
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXCEL THERAPY SPECIALISTS, LLC

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

Provider Business Practice Location Address
First Line	:	1609 N STRONG BLVD
Second Line	:
City	:	MCALESTER
State	:	OK
Zip	:	74501-3839
Country	:	US
Telephone Number	:	918-426-1322
Fax Number	:	918-426-1323

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

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	08/31/2010

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