Provider Demographics
NPI:1497154876
Name:PANHANDLE PHYSICAL THERAPY & WELLNESS, LLC
Entity Type:Organization
Organization Name:PANHANDLE PHYSICAL THERAPY & WELLNESS, LLC
Other - Org Name:PHYSICAL THERAPY ON THE MOVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:BEAU
Authorized Official - Last Name:RAPP
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:918-346-0107
Mailing Address - Street 1:102 S. BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HOOKER
Mailing Address - State:OK
Mailing Address - Zip Code:73945
Mailing Address - Country:US
Mailing Address - Phone:580-652-1111
Mailing Address - Fax:580-652-1111
Practice Address - Street 1:122 E GLAYDAS AVE
Practice Address - Street 2:
Practice Address - City:HOOKER
Practice Address - State:OK
Practice Address - Zip Code:73945-7394
Practice Address - Country:US
Practice Address - Phone:580-652-1111
Practice Address - Fax:580-652-1111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200118240AMedicaid
OKOK400025OtherMEDICARE PTAN