Provider Demographics
NPI:1730251620
Name:EXCEL-ARDMORE LLC
Entity type:Organization
Organization Name:EXCEL-ARDMORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MINNICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-259-9522
Mailing Address - Street 1:2232 W HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-3529
Mailing Address - Country:US
Mailing Address - Phone:918-259-9522
Mailing Address - Fax:918-259-9521
Practice Address - Street 1:2002 12TH STREET NW
Practice Address - Street 2:STE A
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401
Practice Address - Country:US
Practice Address - Phone:580-226-9235
Practice Address - Fax:580-226-9239
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EXCEL THERAPY SPECIALISTS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-15
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK225X00000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5827170001Medicare NSC
OK300522305Medicare PIN