Healthcare Provider Details

I. General information

NPI: 1366824047
Provider Name (Legal Business Name): INTEGRIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 2ND AVE SW
MIAMI OK
74354-6743
US

IV. Provider business mailing address

310 2ND AVE SW
MIAMI OK
74354-6743
US

V. Phone/Fax

Practice location:
  • Phone: 918-540-7736
  • Fax: 918-540-7739
Mailing address:
  • Phone: 918-540-7736
  • Fax: 918-540-7739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: SUSANN MARIE MONTGOMERY
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 918-540-7736