Provider Demographics
NPI:1124283064
Name:OKLAHOMA PHYSICAL THERAPY LAWTON SPINE CARE SPORTS REHAB LLC
Entity type:Organization
Organization Name:OKLAHOMA PHYSICAL THERAPY LAWTON SPINE CARE SPORTS REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:KARA
Authorized Official - Last Name:NICOLE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:405-749-6281
Mailing Address - Street 1:4645 W GORE BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-6041
Mailing Address - Country:US
Mailing Address - Phone:405-749-6281
Mailing Address - Fax:405-936-6496
Practice Address - Street 1:4645 W GORE BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6041
Practice Address - Country:US
Practice Address - Phone:405-749-6281
Practice Address - Fax:405-936-6496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty