Healthcare Provider Details

I. General information

NPI: 1871126383
Provider Name (Legal Business Name): BOOMER 06, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2020
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10921 S WESTERN AVE STE 200
OKLAHOMA CITY OK
73170-6228
US

IV. Provider business mailing address

10921 S WESTERN AVE STE 200
OKLAHOMA CITY OK
73170-6228
US

V. Phone/Fax

Practice location:
  • Phone: 405-996-0660
  • Fax:
Mailing address:
  • Phone: 405-676-5606
  • Fax: 405-676-5374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. RYAN EDWARD ELASSAL
Title or Position: PHYSICAL THERAPIST
Credential:
Phone: 405-996-0660