Provider Demographics
NPI:1326455486
Name:HOME MODS BY THERAPISTS, LLC
Entity Type:Organization
Organization Name:HOME MODS BY THERAPISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERI
Authorized Official - Middle Name:
Authorized Official - Last Name:GILL MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:580-221-3950
Mailing Address - Street 1:3424 MOUNT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-9311
Mailing Address - Country:US
Mailing Address - Phone:580-221-3950
Mailing Address - Fax:
Practice Address - Street 1:3424 MOUNT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-9311
Practice Address - Country:US
Practice Address - Phone:580-221-3950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22422251G0304X
OK600225XE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental ModificationGroup - Multi-Specialty
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200006160AMedicaid