Healthcare Provider Details

I. General information

NPI: 1720919632
Provider Name (Legal Business Name): BO THOMPSON PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 N EASTERN AVE STE 4
MOORE OK
73160-5684
US

IV. Provider business mailing address

2100 N EASTERN AVE STE 4
MOORE OK
73160-5684
US

V. Phone/Fax

Practice location:
  • Phone: 405-676-6030
  • Fax: 405-676-6031
Mailing address:
  • Phone: 405-676-6030
  • Fax: 405-676-6031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6901
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: