Healthcare Provider Details

I. General information

NPI: 1063425023
Provider Name (Legal Business Name): REHABSOURCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 WILL ROGERS PKWY SUITE 600
OKLAHOMA CITY OK
73108-1826
US

IV. Provider business mailing address

4350 WILL ROGERS PKWY SUITE 600
OKLAHOMA CITY OK
73108-1826
US

V. Phone/Fax

Practice location:
  • Phone: 405-943-1144
  • Fax: 405-943-0127
Mailing address:
  • Phone: 405-943-1144
  • Fax: 405-943-0127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MIKE DIMOND
Title or Position: TRUSTEE
Credential:
Phone: 405-943-1144