MEDICARE: MRS. MAGGIE L KENNEDY PTA

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	1464	OK

General Provider Information

NPI Number	:	1972636371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MAGGIE L KENNEDY PTA

Provider Business Mailing Address
First Line	:	2104 N BROADWAY ST
Second Line	:	SUITE B
City	:	POTEAU
State	:	OK
Zip	:	74953-2501
Country	:	US
Telephone Number	:	918-649-0799
Fax Number	:	918-649-0797

Provider Business Practice Location Address
First Line	:	2104 N BROADWAY ST
Second Line	:	SUITE B
City	:	POTEAU
State	:	OK
Zip	:	74953-2501
Country	:	US
Telephone Number	:	918-649-0799
Fax Number	:	918-649-0797

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	07/08/2007

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