Healthcare Provider Details

I. General information

NPI: 1477746741
Provider Name (Legal Business Name): BROKEN ARROW REHABILITATION SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 S ELM PL STE 240
BROKEN ARROW OK
74012-7871
US

IV. Provider business mailing address

2950 S ELM PL STE 240
BROKEN ARROW OK
74012-7871
US

V. Phone/Fax

Practice location:
  • Phone: 918-451-5276
  • Fax: 918-451-5123
Mailing address:
  • Phone: 918-451-5276
  • Fax: 918-451-5123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberOK4055
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberOK19313
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberOK19953
License Number StateOK

VIII. Authorized Official

Name: KRISTINA CLAMMER
Title or Position: OFFICE MANAGER
Credential:
Phone: 918-451-5276