Provider Demographics
NPI:1508492034
Name:SIMMONS, KEN
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9501 ANCHUSA TRL
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78736-2335
Mailing Address - Country:US
Mailing Address - Phone:512-461-1902
Mailing Address - Fax:580-301-6069
Practice Address - Street 1:1100 RANCH RD N
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-1031
Practice Address - Country:US
Practice Address - Phone:580-471-1519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-16
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK707225100000X, 261QP2000X
TX1021988225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty