Provider Demographics
NPI:1679870497
Name:THE PHYSICAL THERAPY ROOM, LLC
Entity Type:Organization
Organization Name:THE PHYSICAL THERAPY ROOM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MCSOUD
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:918-361-9406
Mailing Address - Street 1:4142 S HARVARD AVE
Mailing Address - Street 2:D1
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2623
Mailing Address - Country:US
Mailing Address - Phone:918-742-1156
Mailing Address - Fax:918-770-4818
Practice Address - Street 1:4142 S HARVARD AVE
Practice Address - Street 2:D1
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2623
Practice Address - Country:US
Practice Address - Phone:918-742-1156
Practice Address - Fax:918-770-4818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT3567225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty