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NPI Code Detail

MEDICARE: MR. KELAND JEROME MASK PT

MEDICARE: MR. KELAND JEROME MASK PT
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
1208100000XPhysical Medicine & Rehabilitation Physician1821OK

General Provider Information

NPI Number : 1285688861
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. KELAND JEROME MASK PT
Provider Business Mailing Address
First Line : 6904 E. RENO AVENUE
Second Line :
City : MEDWEST CITY
State : OK
Zip : 73110-2152
Country : US
Telephone Number : 405-737-5555
Fax Number : 405-737-5556
Provider Business Practice Location Address
First Line : 6904 E. RENO AVENUE
Second Line :
City : MIDWEST CITY
State : OK
Zip : 73110-2152
Country : US
Telephone Number : 405-737-5555
Fax Number : 405-737-5556
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/19/2006
Last Update Date : 07/09/2012

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