Basic Information
| Provider Information | |||||||||
| NPI: | 1982772695 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOREN | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PT, MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2103 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ELK CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736449166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802250075 | ||||||||
| FaxNumber: | 5802250095 | ||||||||
| Practice Location | |||||||||
| Address1: | 2103 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ELK CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736449166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802250075 | ||||||||
| FaxNumber: | 5802250095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 06/12/2013 | ||||||||
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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 | 3785 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 3785 | 01 | OK | PT LICENSE | OTHER |