Healthcare Provider Details

I. General information

NPI: 1124283064
Provider Name (Legal Business Name): OKLAHOMA PHYSICAL THERAPY LAWTON SPINE CARE SPORTS REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4645 W GORE BLVD SUITE E
LAWTON OK
73505-6041
US

IV. Provider business mailing address

4645 W GORE BLVD SUITE E
LAWTON OK
73505-6041
US

V. Phone/Fax

Practice location:
  • Phone: 405-749-6281
  • Fax: 405-936-6496
Mailing address:
  • Phone: 405-749-6281
  • Fax: 405-936-6496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LEE KARA NICOLE
Title or Position: DIRECTOR
Credential: PT
Phone: 405-749-6281