Healthcare Provider Details

I. General information

NPI: 1093709628
Provider Name (Legal Business Name): SOUTHEASTERN OKLAHOMA OUTPATIENT REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 LINCOLN RD SUITE B-3
IDABEL OK
74745-7345
US

IV. Provider business mailing address

PO BOX 3070
TEXARKANA TX
75504-3070
US

V. Phone/Fax

Practice location:
  • Phone: 580-286-4842
  • Fax: 903-735-5399
Mailing address:
  • Phone: 903-735-5356
  • Fax: 903-735-5399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateOK

VIII. Authorized Official

Name: NANCY BARLOW
Title or Position: ADMINISTRATOR
Credential:
Phone: 903-614-4402