Healthcare Provider Details

I. General information

NPI: 1790048882
Provider Name (Legal Business Name): GUYMON PHYSICAL THERAPY AND WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 NW 5TH ST
GUYMON OK
73942-5801
US

IV. Provider business mailing address

211 NW 5TH ST
GUYMON OK
73942-5801
US

V. Phone/Fax

Practice location:
  • Phone: 580-338-4789
  • Fax: 866-999-0184
Mailing address:
  • Phone: 580-338-4789
  • Fax: 866-999-0184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number1929
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number3766
License Number StateOK

VIII. Authorized Official

Name: JACOB LEE TUTTLE
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: PT
Phone: 918-223-5075