Healthcare Provider Details

I. General information

NPI: 1285662916
Provider Name (Legal Business Name): RICKY NEIL RISENHOOVER RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 PLAZA SOUTH ST
TAHLEQUAH OK
74464-4750
US

IV. Provider business mailing address

23 PLAZA SOUTH
TAHLEQUAH OK
74464
US

V. Phone/Fax

Practice location:
  • Phone: 918-431-1919
  • Fax: 918-431-1636
Mailing address:
  • Phone: 918-431-1919
  • Fax: 918-431-1636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1606
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: