Basic Information
| Provider Information | |||||||||
| NPI: | 1285061606 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OKLAHOMA PHYSICAL THERAPY CHOCTAW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3705 W MEMORIAL RD | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731341512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057496281 | ||||||||
| FaxNumber: | 4059366496 | ||||||||
| Practice Location | |||||||||
| Address1: | 1960 HARPER ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CHOCTAW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730208095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052815785 | ||||||||
| FaxNumber: | 4052815786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2013 | ||||||||
| LastUpdateDate: | 11/05/2013 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | KARA | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| 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 | 3512418726 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.