Provider Demographics
NPI:1568685865
Name:EXCEL PHYSICAL THERAPY INSTITUTE, LLC
Entity Type:Organization
Organization Name:EXCEL PHYSICAL THERAPY INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:G
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:405-455-3784
Mailing Address - Street 1:1212 S AIR DEPOT BLVD
Mailing Address - Street 2:SUITE 17
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-4870
Mailing Address - Country:US
Mailing Address - Phone:405-455-3784
Mailing Address - Fax:405-455-3844
Practice Address - Street 1:1212 S AIR DEPOT BLVD
Practice Address - Street 2:SUITE 17
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4870
Practice Address - Country:US
Practice Address - Phone:405-455-3784
Practice Address - Fax:405-455-3844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy