Basic Information
| Provider Information | |||||||||
| NPI: | 1205352028 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CUTTING EDGE PHYSICAL THERAPY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 526 SW 4TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731605409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057592700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1805 COMMONS CIR STE 100-B | ||||||||
| Address2: | |||||||||
| City: | YUKON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730999519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052651628 | ||||||||
| FaxNumber: | 4052651929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2017 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | WALLACE | ||||||||
| AuthorizedOfficialFirstName: | SHAWN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4052651628 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CUTTING EDGE PHYSICAL THERAPY, PLLC | ||||||||
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| NPICertificationDate: | 09/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.