Provider Demographics
NPI:1215266671
Name:FUNDAMENTAL PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:FUNDAMENTAL PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:405-513-8118
Mailing Address - Street 1:PO BOX 3542
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-3542
Mailing Address - Country:US
Mailing Address - Phone:405-513-8118
Mailing Address - Fax:
Practice Address - Street 1:3500 S BOULEVARD
Practice Address - Street 2:SUITE A1
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5486
Practice Address - Country:US
Practice Address - Phone:405-518-8118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-15
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK821261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy