=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508492034
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEN SIMMONS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2020
-----------------------------------------------------
Last Update Date | 11/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 RANCH RD N
-----------------------------------------------------
City | ALTUS
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73521-1031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-471-1519
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9501 ANCHUSA TRL
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78736-2335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-461-1902
-----------------------------------------------------
Fax | 580-301-6069
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 707
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 707
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1021988
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------