1073560942 NPI number — GRAND SLAM REHABILITATION L.L.C.

Table of content: MARY SUSAN DUNN PT (NPI 1003802802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073560942 NPI number — GRAND SLAM REHABILITATION L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND SLAM REHABILITATION L.L.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073560942
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6510 S WESTERN AVE
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73139-1712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-631-8888
Provider Business Mailing Address Fax Number:
405-631-9593

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6510 S WESTERN AVE
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73139-1712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-631-8888
Provider Business Practice Location Address Fax Number:
405-631-9593
Provider Enumeration Date:
05/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PRENTICE
Authorized Official First Name:
DEREK
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
405-418-2200

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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