Healthcare Provider Details

I. General information

NPI: 1659090991
Provider Name (Legal Business Name): KARI LAMAE GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22087 BLACK WALNUT CIR
EDMOND OK
73012-4228
US

IV. Provider business mailing address

22087 BLACK WALNUT CIR
EDMOND OK
73012-4228
US

V. Phone/Fax

Practice location:
  • Phone: 405-880-5120
  • Fax:
Mailing address:
  • Phone: 405-612-0616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number1707
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: