Provider Demographics
NPI:1942624135
Name:EAGLE SPORTS MEDICINE
Entity Type:Organization
Organization Name:EAGLE SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REHABILITATION COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:KRAUSE
Authorized Official - Suffix:
Authorized Official - Credentials:PT/ATC
Authorized Official - Phone:580-272-4978
Mailing Address - Street 1:2501 E MEMORIAL RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5525
Mailing Address - Country:US
Mailing Address - Phone:405-425-1960
Mailing Address - Fax:405-425-1962
Practice Address - Street 1:2501 E MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5525
Practice Address - Country:US
Practice Address - Phone:405-425-1960
Practice Address - Fax:405-425-1962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-10
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2813261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation