Healthcare Provider Details

I. General information

NPI: 1265700256
Provider Name (Legal Business Name): HUMBERTO GRIMALDO-SALAZAR PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2011
Last Update Date: 12/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N 5TH AVE
MADILL OK
73446-1200
US

IV. Provider business mailing address

811 W BURNEY ST
MADILL OK
73446-2642
US

V. Phone/Fax

Practice location:
  • Phone: 580-795-3301
  • Fax: 580-795-7307
Mailing address:
  • Phone: 580-263-8484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1948
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: