Provider Demographics
NPI:1679172993
Name:ABC PEDIATRIC REHAB LLC
Entity Type:Organization
Organization Name:ABC PEDIATRIC REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PTA
Authorized Official - Prefix:MISS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALVARADO
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:405-845-3389
Mailing Address - Street 1:1808 DOROTHY DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73170-1457
Mailing Address - Country:US
Mailing Address - Phone:405-570-2672
Mailing Address - Fax:
Practice Address - Street 1:508 W I 240 SERVICE RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-4400
Practice Address - Country:US
Practice Address - Phone:405-724-9303
Practice Address - Fax:405-724-9617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-19
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports MedicineGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200950830AMedicaid