Provider Demographics
NPI:1952475154
Name:FUNCTIONAL ASSESTMENT CENTERS OF OKLAHOMA
Entity Type:Organization
Organization Name:FUNCTIONAL ASSESTMENT CENTERS OF OKLAHOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:405-879-6766
Mailing Address - Street 1:409 E. CALIFORNIA AVE.
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104
Mailing Address - Country:US
Mailing Address - Phone:405-879-6766
Mailing Address - Fax:405-879-3493
Practice Address - Street 1:409 E. CALIFORNIA AVE.
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104
Practice Address - Country:US
Practice Address - Phone:405-879-6766
Practice Address - Fax:405-879-3493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT2855261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy