Basic Information
| Provider Information | |||||||||
| NPI: | 1417260654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | JUSTIN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6585 S YALE AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741368384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184812767 | ||||||||
| FaxNumber: | 9184817611 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 S ASPEN AVE | ||||||||
| Address2: | |||||||||
| City: | BROKEN ARROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740122296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189945333 | ||||||||
| FaxNumber: | 9189945334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2010 | ||||||||
| LastUpdateDate: | 12/12/2011 | ||||||||
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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 | 4311 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.