Provider Demographics
NPI:1023704236
Name:THE SHINE PEDIATRIC THERAPY CENTER
Entity type:Organization
Organization Name:THE SHINE PEDIATRIC THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WONDERLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-708-7172
Mailing Address - Street 1:921 W MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-4328
Mailing Address - Country:US
Mailing Address - Phone:405-612-8396
Mailing Address - Fax:
Practice Address - Street 1:921 W MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-4328
Practice Address - Country:US
Practice Address - Phone:405-612-8396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty