MEDICARE: SHEPHERD MALL THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QH0700X	Hearing and Speech Clinic/Center
2	261QX0100X	Occupational Medicine Clinic/Center
3	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1285136135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHEPHERD MALL THERAPY LLC

Provider Business Mailing Address
First Line	:	4334 NW EXPRESSWAY STE 187
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-1515
Country	:	US
Telephone Number	:
Fax Number	:	405-212-4270

Provider Business Practice Location Address
First Line	:	2401 NW 23RD ST STE 2D
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73107-2420
Country	:	US
Telephone Number	:	405-355-3239
Fax Number	:	405-212-4270

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DOUGLAS EDWIN BROWN JR.
Credential	:
Telephone Number	:	405-355-3239

Provider Enumeration Date	:	03/07/2018
Last Update Date	:	03/07/2018

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