Provider Demographics
NPI:1003072729
Name:PREFERRED PHYSICAL THERAPY BROKEN ARROW, PLLC
Entity Type:Organization
Organization Name:PREFERRED PHYSICAL THERAPY BROKEN ARROW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:TODD
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:316-260-6869
Mailing Address - Street 1:200 W DOUGLAS AVE
Mailing Address - Street 2:STE. 1040
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-3013
Mailing Address - Country:US
Mailing Address - Phone:316-263-0003
Mailing Address - Fax:316-263-1241
Practice Address - Street 1:2033 W HOUSTON ST
Practice Address - Street 2:STE. A
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8304
Practice Address - Country:US
Practice Address - Phone:918-259-0374
Practice Address - Fax:918-259-0376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-01
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200208130AMedicaid
OKOKB5364Medicare PIN