Provider Demographics
NPI:1275802639
Name:NORTHEASTERN PHYSICAL REHAB
Entity Type:Organization
Organization Name:NORTHEASTERN PHYSICAL REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:918-458-5115
Mailing Address - Street 1:2021 MAHANEY AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-5795
Mailing Address - Country:US
Mailing Address - Phone:918-458-5115
Mailing Address - Fax:918-458-5119
Practice Address - Street 1:2021 MAHANEY AVE STE 6
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5795
Practice Address - Country:US
Practice Address - Phone:918-458-5115
Practice Address - Fax:918-458-5119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2083261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy