Provider Demographics
NPI:1144456617
Name:DOMINION THERAPY & EDUCATION
Entity type:Organization
Organization Name:DOMINION THERAPY & EDUCATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:FUKSA
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:580-234-1115
Mailing Address - Street 1:723 W RANDOLPH AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-3826
Mailing Address - Country:US
Mailing Address - Phone:580-234-1115
Mailing Address - Fax:580-234-1150
Practice Address - Street 1:723 W RANDOLPH AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-3826
Practice Address - Country:US
Practice Address - Phone:580-234-1115
Practice Address - Fax:580-234-1150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3116225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty