Basic Information
| Provider Information | |||||||||
| NPI: | 1598152407 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUM | ||||||||
| FirstName: | JUSTIN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4812 E 33RD ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741352038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186224126 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12326 E 86TH ST N | ||||||||
| Address2: | |||||||||
| City: | OWASSO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182723750 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2015 | ||||||||
| LastUpdateDate: | 09/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4972 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.