Healthcare Provider Details

I. General information

NPI: 1417078668
Provider Name (Legal Business Name): CHICKASHA PHYSICAL THERAPY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

626 W KANSAS AVE
CHICKASHA OK
73018
US

IV. Provider business mailing address

626 W KANSAS AVE
CHICKASHA OK
73018
US

V. Phone/Fax

Practice location:
  • Phone: 405-222-5030
  • Fax: 405-222-5050
Mailing address:
  • Phone: 405-222-5030
  • Fax: 405-222-5050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number464
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number124
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number464
License Number StateOK

VIII. Authorized Official

Name: BRENDA HORN
Title or Position: OWNER
Credential: PT
Phone: 405-222-5030