Provider Demographics
NPI:1336498864
Name:IMC OF OKLAHOMA, LLC
Entity Type:Organization
Organization Name:IMC OF OKLAHOMA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE & BILLING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:ATKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-656-1837
Mailing Address - Street 1:2615 CENTENNIAL BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-0586
Mailing Address - Country:US
Mailing Address - Phone:850-656-1837
Mailing Address - Fax:850-877-2917
Practice Address - Street 1:1105 MICHELIN RD
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1085
Practice Address - Country:US
Practice Address - Phone:580-224-4446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-30
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4626225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty