Basic Information
| Provider Information | |||||||||
| NPI: | 1508272006 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CUTTING EDGE PHYSICAL THERAPY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 526 SW 4TH ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MOORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731604928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057592700 | ||||||||
| FaxNumber: | 4057592722 | ||||||||
| Practice Location | |||||||||
| Address1: | 526 SW 4TH ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MOORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731604928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057592700 | ||||||||
| FaxNumber: | 4057592722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2014 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | WALLACE | ||||||||
| AuthorizedOfficialFirstName: | SHAWN | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4056200145 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 1796 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.