Basic Information
| Provider Information | |||||||||
| NPI: | 1114268018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEACH | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | RAY | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 724 24TH AVE., N.W. | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054471571 | ||||||||
| FaxNumber: | 4054471579 | ||||||||
| Practice Location | |||||||||
| Address1: | 724 24TH AVE., N.W. | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054471571 | ||||||||
| FaxNumber: | 4054471579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2013 | ||||||||
| LastUpdateDate: | 03/04/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 819 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.