MEDICARE: AMBER PRINCE PTA

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	225200000X	Physical Therapy Assistant	1269	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	:	1659500965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMBER PRINCE PTA

Provider Business Mailing Address
First Line	:	10100 FOREST HILLS RD
Second Line	:
City	:	MACHESNEY PARK
State	:	IL
Zip	:	61115-8234
Country	:	US
Telephone Number	:	815-713-2738
Fax Number	:	815-713-2797

Provider Business Practice Location Address
First Line	:	2334 SE WASHINGTON BLVD
Second Line	:
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006-7256
Country	:	US
Telephone Number	:	918-331-9184
Fax Number	:	918-331-9187

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2009
Last Update Date	:	07/08/2009

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Directions to “ AMBER PRINCE PTA” Practice Location

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