=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730696121
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOPE RENEWED THERAPY AND WELLNESS CENTER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2018
-----------------------------------------------------
Last Update Date | 01/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 S SANTA FE AVE STE 103
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73003-6286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-589-5922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 515 S SANTA FE AVE STE 103
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73003-6286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-589-5922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RHONDA DIANE PENNINGTON
-----------------------------------------------------
Credential | OT
-----------------------------------------------------
Telephone | 405-589-5922
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 133
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------