MEDICARE: HOME MODS BY THERAPISTS, 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	2251G0304X	Geriatric Physical Therapist	2242	OK
2	225XE0001X	Environmental Modification Occupational Therapist	600	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326455486
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOME MODS BY THERAPISTS, LLC

Provider Business Mailing Address
First Line	:	3424 MOUNT WASHINGTON RD
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-9311
Country	:	US
Telephone Number	:	580-221-3950
Fax Number	:

Provider Business Practice Location Address
First Line	:	3424 MOUNT WASHINGTON RD
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-9311
Country	:	US
Telephone Number	:	580-221-3950
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JERI GILL MCKENZIE
Credential	:	RPT
Telephone Number	:	580-221-3950

Provider Enumeration Date	:	07/21/2014
Last Update Date	:	07/21/2014

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