Provider Demographics
NPI:1790048882
Name:GUYMON PHYSICAL THERAPY AND WELLNESS PLLC
Entity type:Organization
Organization Name:GUYMON PHYSICAL THERAPY AND WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:TUTTLE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:918-223-5075
Mailing Address - Street 1:211 NW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-5801
Mailing Address - Country:US
Mailing Address - Phone:580-338-4789
Mailing Address - Fax:866-999-0184
Practice Address - Street 1:211 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-5801
Practice Address - Country:US
Practice Address - Phone:580-338-4789
Practice Address - Fax:866-999-0184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1929261QP2000X
225X00000X
OK3766261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK12413288OtherCAQH
OK200459990AMedicaid