Provider Demographics
NPI:1508272006
Name:CUTTING EDGE PHYSICAL THERAPY PLLC
Entity Type:Organization
Organization Name:CUTTING EDGE PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:G
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-620-0145
Mailing Address - Street 1:526 SW 4TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-4928
Mailing Address - Country:US
Mailing Address - Phone:405-759-2700
Mailing Address - Fax:405-759-2722
Practice Address - Street 1:526 SW 4TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-4928
Practice Address - Country:US
Practice Address - Phone:405-759-2700
Practice Address - Fax:405-759-2722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-03
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1796261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy