Provider Demographics
NPI:1417078668
Name:CHICKASHA PHYSICAL THERAPY CLINIC
Entity Type:Organization
Organization Name:CHICKASHA PHYSICAL THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HORN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:405-222-5030
Mailing Address - Street 1:626 W KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018
Mailing Address - Country:US
Mailing Address - Phone:405-222-5030
Mailing Address - Fax:405-222-5050
Practice Address - Street 1:626 W KANSAS AVE
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018
Practice Address - Country:US
Practice Address - Phone:405-222-5030
Practice Address - Fax:405-222-5050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK464225100000X, 2251S0007X
OK124225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========002OtherBCBS PAYOR ID
=========002OtherBCBS PAYOR ID