Provider Demographics
NPI:1376849364
Name:MELODY THOMASON, PT, PC
Entity Type:Organization
Organization Name:MELODY THOMASON, PT, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:RONNAE
Authorized Official - Last Name:THOMASON
Authorized Official - Suffix:
Authorized Official - Credentials:PT, ATP
Authorized Official - Phone:405-517-8387
Mailing Address - Street 1:PO BOX 12036
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73157-2036
Mailing Address - Country:US
Mailing Address - Phone:405-605-1466
Mailing Address - Fax:405-605-1467
Practice Address - Street 1:6108 NW 63RD ST STE B
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-7553
Practice Address - Country:US
Practice Address - Phone:405-605-1466
Practice Address - Fax:405-605-1467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1696261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100835160BMedicaid