1497154876 NPI number — PANHANDLE PHYSICAL THERAPY & WELLNESS, LLC

Table of content: (NPI 1497154876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497154876 NPI number — PANHANDLE PHYSICAL THERAPY & WELLNESS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PANHANDLE PHYSICAL THERAPY & WELLNESS, LLC
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:
6
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:
1497154876
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 S. BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOOKER
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-652-1111
Provider Business Mailing Address Fax Number:
580-652-1111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
122 E GLAYDAS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOOKER
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73945-7394
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-652-1111
Provider Business Practice Location Address Fax Number:
580-652-1111
Provider Enumeration Date:
08/21/2014

Additional Information

Authorized Official

Authorized Official Last Name:
RAPP
Authorized Official First Name:
JEREMY
Authorized Official Middle Name:
BEAU
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
918-346-0107

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)

  • Identifier: 200118240A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: OK400025 . This is a "MEDICARE PTAN" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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