Provider Demographics
NPI:1154645547
Name:ZUCKSWORTH, ELI S (ATC)
Entity Type:Individual
Prefix:MR
First Name:ELI
Middle Name:S
Last Name:ZUCKSWORTH
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 E ASH ST
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-3935
Mailing Address - Country:US
Mailing Address - Phone:405-880-5725
Mailing Address - Fax:
Practice Address - Street 1:1112 E ASH ST
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-3935
Practice Address - Country:US
Practice Address - Phone:405-880-5725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer