Provider Demographics
NPI:1316791452
Name:LOUDERBACK, BAILE LANE (DPT)
Entity type:Individual
Prefix:
First Name:BAILE
Middle Name:LANE
Last Name:LOUDERBACK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2488 E 81ST ST STE 290
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-4299
Mailing Address - Country:US
Mailing Address - Phone:918-927-3199
Mailing Address - Fax:918-927-3193
Practice Address - Street 1:2488 E 81ST ST STE 290
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-4299
Practice Address - Country:US
Practice Address - Phone:918-927-3199
Practice Address - Fax:918-927-3193
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK225100000X
OK6585225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist