Provider Demographics
NPI:1386860831
Name:BROOMFIELD, ROGER LEE (PT)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:LEE
Last Name:BROOMFIELD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11918 SPRINGRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72916-8189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11918 SPRINGRIDGE DR
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72916-8189
Practice Address - Country:US
Practice Address - Phone:479-649-9558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1639225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist