Provider Demographics
NPI:1952139388
Name:BESPOKE PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:BESPOKE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NIKOLAUS
Authorized Official - Middle Name:
Authorized Official - Last Name:PRESCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:918-841-6257
Mailing Address - Street 1:4907 E GALVESTON PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-2342
Mailing Address - Country:US
Mailing Address - Phone:918-841-6257
Mailing Address - Fax:539-399-7520
Practice Address - Street 1:4907 E GALVESTON PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-2342
Practice Address - Country:US
Practice Address - Phone:918-841-6257
Practice Address - Fax:539-399-7520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy