Provider Demographics
NPI: | 1417668674 |
---|---|
Name: | ELITE PEDS OK LLC |
Entity Type: | Organization |
Organization Name: | ELITE PEDS OK LLC |
Other - Org Name: | ELITE PEDIATRIC THERAPY |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ALEXIS |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | LANGSTON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | OTR |
Authorized Official - Phone: | 918-766-5233 |
Mailing Address - Street 1: | 6385 E 124TH CT S |
Mailing Address - Street 2: | |
Mailing Address - City: | BIXBY |
Mailing Address - State: | OK |
Mailing Address - Zip Code: | 74008-5894 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 918-417-8740 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 4800 W SAN ANTONIO ST STE 103 |
Practice Address - Street 2: | |
Practice Address - City: | BROKEN ARROW |
Practice Address - State: | OK |
Practice Address - Zip Code: | 74012-6127 |
Practice Address - Country: | US |
Practice Address - Phone: | 918-417-8740 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2022-12-08 |
Last Update Date: | 2022-12-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Single Specialty |