Basic Information
| Provider Information | |||||||||
| NPI: | 1124283064 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OKLAHOMA PHYSICAL THERAPY LAWTON SPINE CARE SPORTS REHAB LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4645 W GORE BLVD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057496281 | ||||||||
| FaxNumber: | 4059366496 | ||||||||
| Practice Location | |||||||||
| Address1: | 4645 W GORE BLVD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057496281 | ||||||||
| FaxNumber: | 4059366496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | NICOLE | ||||||||
| AuthorizedOfficialFirstName: | LEE | ||||||||
| AuthorizedOfficialMiddleName: | KARA | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4057496281 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.