Healthcare Provider Details

I. General information

NPI: 1679172993
Provider Name (Legal Business Name): ABC PEDIATRIC REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 W I 240 SERVICE RD
OKLAHOMA CITY OK
73139-4400
US

IV. Provider business mailing address

1808 DOROTHY DR
MOORE OK
73170-1457
US

V. Phone/Fax

Practice location:
  • Phone: 405-724-9303
  • Fax: 405-724-9617
Mailing address:
  • Phone: 405-570-2672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MISS VICTORIA ALVARADO
Title or Position: OWNER/PTA
Credential: PTA
Phone: 405-845-3389