Provider Demographics
NPI:1639351109
Name:PROFESSIONAL REHAB & ORTHO PT
Entity Type:Organization
Organization Name:PROFESSIONAL REHAB & ORTHO PT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SIEGENTHALER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:918-809-8666
Mailing Address - Street 1:9120 FERGUSON RD
Mailing Address - Street 2:
Mailing Address - City:BEGGS
Mailing Address - State:OK
Mailing Address - Zip Code:74421-2384
Mailing Address - Country:US
Mailing Address - Phone:918-267-3180
Mailing Address - Fax:
Practice Address - Street 1:9120 FERGUSON RD
Practice Address - Street 2:
Practice Address - City:BEGGS
Practice Address - State:OK
Practice Address - Zip Code:74421-2384
Practice Address - Country:US
Practice Address - Phone:918-267-3180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2167225100000X
OK735225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty