Healthcare Provider Details

I. General information

NPI: 1639298821
Provider Name (Legal Business Name): HEATH HANOCH MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 S OLYMPIA AVE
TULSA OK
74132-1843
US

IV. Provider business mailing address

10919 S 91ST EAST CT
TULSA OK
74133-6323
US

V. Phone/Fax

Practice location:
  • Phone: 918-388-5701
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2860
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: