Healthcare Provider Details

I. General information

NPI: 1992829360
Provider Name (Legal Business Name): RALPH FREDERICK JEROME PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 10/15/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 EVANS AVENUE
MANNFORD OK
74044
US

IV. Provider business mailing address

PO BOX 361
MANNFORD OK
74044-0361
US

V. Phone/Fax

Practice location:
  • Phone: 918-865-7020
  • Fax: 918-865-7039
Mailing address:
  • Phone: 918-865-7020
  • Fax: 918-865-7039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2974
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: