Healthcare Provider Details

I. General information

NPI: 1003019167
Provider Name (Legal Business Name): MICHAEL RAYMOND CHILDRESS RPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2408 E 81ST ST STE 300
TULSA OK
74137-4200
US

IV. Provider business mailing address

2408 E 81ST ST STE 300
TULSA OK
74137-4200
US

V. Phone/Fax

Practice location:
  • Phone: 918-477-5053
  • Fax: 918-477-5040
Mailing address:
  • Phone: 918-477-5053
  • Fax: 918-477-5040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number770
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: