Provider Demographics
NPI:1700858842
Name:HARGROVE, LEE KENNETH (PT)
Entity Type:Individual
Prefix:MR
First Name:LEE
Middle Name:KENNETH
Last Name:HARGROVE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 S YALE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-6017
Mailing Address - Country:US
Mailing Address - Phone:918-622-4278
Mailing Address - Fax:918-622-4844
Practice Address - Street 1:4004 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6017
Practice Address - Country:US
Practice Address - Phone:918-622-4278
Practice Address - Fax:918-622-4844
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT2359225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
200094780AOtherMEDICAID LEGACY
OK200094780AMedicaid
7589153OtherAETNA
444649810010OtherBCBS LEGACY
243631705OtherMEDICARE LEGACY
P00382679OtherMEDICARE RAILRAOD
243631705OtherMEDICARE LEGACY