Provider Demographics
NPI:1700087079
Name:THERAWEST LLC
Entity Type:Organization
Organization Name:THERAWEST LLC
Other - Org Name:THERAWEST REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:580-323-8778
Mailing Address - Street 1:PO BOX 86
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73601-0086
Mailing Address - Country:US
Mailing Address - Phone:580-323-8778
Mailing Address - Fax:580-323-8732
Practice Address - Street 1:509 S. 30TH STREET
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-0086
Practice Address - Country:US
Practice Address - Phone:580-323-8778
Practice Address - Fax:580-323-8732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2536225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK73159OtherFIRST HEALTH/ KEMPTON CO.
OK73159OtherTHE KEMPTON CO
OK=========001OtherBLUECROSS & BLUESHIELD