Provider Demographics
NPI:1073560942
Name:GRAND SLAM REHABILITATION L.L.C.
Entity Type:Organization
Organization Name:GRAND SLAM REHABILITATION L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:PRENTICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-418-2200
Mailing Address - Street 1:6510 S WESTERN AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-1712
Mailing Address - Country:US
Mailing Address - Phone:405-631-8888
Mailing Address - Fax:405-631-9593
Practice Address - Street 1:6510 S WESTERN AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-1712
Practice Address - Country:US
Practice Address - Phone:405-631-8888
Practice Address - Fax:405-631-9593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK376537Medicare Oscar/Certification