Provider Demographics
NPI:1417668674
Name:ELITE PEDS OK LLC
Entity type:Organization
Organization Name:ELITE PEDS OK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LANGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:918-766-5233
Mailing Address - Street 1:6385 E 124TH CT S
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-5894
Mailing Address - Country:US
Mailing Address - Phone:918-417-8740
Mailing Address - Fax:
Practice Address - Street 1:4800 W SAN ANTONIO ST # 101
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-6127
Practice Address - Country:US
Practice Address - Phone:918-417-8740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-08
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK201125410Medicaid