Provider Demographics
NPI:1649643180
Name:EXCEL THERAPY SPECIALISTS--OKC LLC
Entity type:Organization
Organization Name:EXCEL THERAPY SPECIALISTS--OKC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WAGONER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-259-1888
Mailing Address - Street 1:2234-B W HOUSTON
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-3519
Mailing Address - Country:US
Mailing Address - Phone:918-259-1888
Mailing Address - Fax:918-251-3725
Practice Address - Street 1:1742 S 4TH ST
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-5901
Practice Address - Country:US
Practice Address - Phone:405-825-3617
Practice Address - Fax:405-825-3618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200620300AMedicaid
OK200620300AMedicaid