Provider Demographics
NPI:1881699130
Name:OKLAHOMA MANUAL THERAPY ASSOCIATES, PLLC
Entity type:Organization
Organization Name:OKLAHOMA MANUAL THERAPY ASSOCIATES, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/ PHYSICAL THERAPY
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, OCS, FAAOMPT
Authorized Official - Phone:405-285-8477
Mailing Address - Street 1:1410 FRETZ DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-5782
Mailing Address - Country:US
Mailing Address - Phone:405-285-8477
Mailing Address - Fax:405-285-8499
Practice Address - Street 1:1410 FRETZ DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-5782
Practice Address - Country:US
Practice Address - Phone:405-285-8477
Practice Address - Fax:405-285-8499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========001OtherBCBS GROUP
OK400522422Medicare PIN