Basic Information
| Provider Information | |||||||||
| NPI: | 1275802639 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEASTERN PHYSICAL REHAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2021 MAHANEY AVE STE 6 | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744645795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184585115 | ||||||||
| FaxNumber: | 9184585119 | ||||||||
| Practice Location | |||||||||
| Address1: | 2021 MAHANEY AVE STE 6 | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744645795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184585115 | ||||||||
| FaxNumber: | 9184585119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2011 | ||||||||
| LastUpdateDate: | 12/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | SCOTT | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | BRENT | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 9184585115 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 2083 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.