Provider Demographics
NPI:1205352028
Name:CUTTING EDGE PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:CUTTING EDGE PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-265-1628
Mailing Address - Street 1:526 SW 4TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-5409
Mailing Address - Country:US
Mailing Address - Phone:405-759-2700
Mailing Address - Fax:
Practice Address - Street 1:1805 COMMONS CIR STE 100-B
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-9519
Practice Address - Country:US
Practice Address - Phone:405-265-1628
Practice Address - Fax:405-265-1929
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CUTTING EDGE PHYSICAL THERAPY, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-15
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy