Provider Demographics
NPI:1073659033
Name:OKLAHOMA PHYSICAL THERAPY SPINE CARE - REHAB, L.L.C.
Entity Type:Organization
Organization Name:OKLAHOMA PHYSICAL THERAPY SPINE CARE - REHAB, L.L.C.
Other - Org Name:OKLAHOMA PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MANNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-749-6281
Mailing Address - Street 1:1925 NW 142ND ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-6193
Mailing Address - Country:US
Mailing Address - Phone:405-749-6281
Mailing Address - Fax:405-936-6496
Practice Address - Street 1:1925 NW 142ND ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-6193
Practice Address - Country:US
Practice Address - Phone:405-749-6281
Practice Address - Fax:405-936-6496
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OKLAHOMA PHYSICAL THERAPY SPINE CARE REHAB., LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-29
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK710899208174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200567570BMedicaid
OK200567570AMedicaid