=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952889826
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDE T SIMO SR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2018
-----------------------------------------------------
Last Update Date | 08/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1414 SW 89TH ST STE A
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73159-6312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-703-8424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1205 NW 14TH PL
-----------------------------------------------------
City | MOORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73170-1469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-604-7973
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 1568
-----------------------------------------------------
License Number State |
-----------------------------------------------------