Provider Demographics
NPI:1497006456
Name:PENNEY REHAB AND WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:PENNEY REHAB AND WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:PENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:580-927-0197
Mailing Address - Street 1:1004 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:COALGATE
Mailing Address - State:OK
Mailing Address - Zip Code:74538-2662
Mailing Address - Country:US
Mailing Address - Phone:580-927-9121
Mailing Address - Fax:888-780-0916
Practice Address - Street 1:1004 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:COALGATE
Practice Address - State:OK
Practice Address - Zip Code:74538-2662
Practice Address - Country:US
Practice Address - Phone:580-927-9121
Practice Address - Fax:888-780-0916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-30
Last Update Date:2012-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2868261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy