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General NPI Number Information
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NPI Number | 1528303872
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Entity Type | Individual
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Provider Name | SAM VALE PENNY LPTA
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Gender | Male
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Dates
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Enumeration Date | 11/27/2012
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Last Update Date | 11/27/2012
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Provider Practice Location Address
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Address Line | 1601 ACADEMY RD
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City | PONCA CITY
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State | OK
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Zip | 74604-4409
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Country | US
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Telephone | 580-762-0927
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Fax | 580-762-0933
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Provider Business Mailing Address
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Address Line | 419 E BROADWAY ST
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City | CUSHING
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State | OK
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Zip | 74023-3339
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Country | US
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Telephone | 918-509-0967
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 675
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License Number State | OK
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