Provider Demographics
NPI:1528161833
Name:POWER SHOP
Entity type:Organization
Organization Name:POWER SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:PATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-252-4516
Mailing Address - Street 1:2103 W BEECH AVE
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-2334
Mailing Address - Country:US
Mailing Address - Phone:580-252-4516
Mailing Address - Fax:580-252-6903
Practice Address - Street 1:2103 W BEECH AVE
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-2334
Practice Address - Country:US
Practice Address - Phone:580-252-4516
Practice Address - Fax:580-252-6903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103TC1900X251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services