Healthcare Provider Details

I. General information

NPI: 1285850503
Provider Name (Legal Business Name): JIMMY LLOYD LYTAL PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 NW EXPRESSWAY ST SUITE 809
OKLAHOMA CITY OK
73112-5474
US

IV. Provider business mailing address

713 NORTH VERNON STREET
HINTON OK
73047-9106
US

V. Phone/Fax

Practice location:
  • Phone: 405-917-7160
  • Fax: 405-917-7161
Mailing address:
  • Phone: 405-542-3227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1309
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: