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General NPI Number Information
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NPI Number | 1023704236
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Entity Type | Organization
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Legal Business Name | THE SHINE PEDIATRIC THERAPY CENTER
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Dates
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Enumeration Date | 04/12/2023
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Last Update Date | 04/12/2023
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Provider Practice Location Address
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Address Line | 921 W MISSOURI AVE
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City | CHICKASHA
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State | OK
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Zip | 73018-4328
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Country | US
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Telephone | 405-612-8396
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Fax |
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Provider Business Mailing Address
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Address Line | 921 W MISSOURI AVE
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City | CHICKASHA
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State | OK
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Zip | 73018-4328
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Country | US
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Telephone | 405-612-8396
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JUSTIN WONDERLY
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Credential |
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Telephone | 405-708-7172
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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