Healthcare Provider Details

I. General information

NPI: 1124731062
Provider Name (Legal Business Name): TALIA FORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2023
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3029 W MAIN ST
JENKS OK
74037-3465
US

IV. Provider business mailing address

13680 KENOSHA AVE
GLENPOOL OK
74033-3829
US

V. Phone/Fax

Practice location:
  • Phone: 918-701-2300
  • Fax:
Mailing address:
  • Phone: 918-639-9013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3558
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: