Healthcare Provider Details

I. General information

NPI: 1447337423
Provider Name (Legal Business Name): NORTHEASTERN PHYSICAL REHAB, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E DOWNING ST STE 210
TAHLEQUAH OK
74464-3379
US

IV. Provider business mailing address

1500 E DOWNING ST STE 210
TAHLEQUAH OK
74464-3379
US

V. Phone/Fax

Practice location:
  • Phone: 918-458-5115
  • Fax: 818-458-5119
Mailing address:
  • Phone: 918-458-5115
  • Fax: 818-458-5119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1994
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier175254900
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerDEPT OF LABOR
# 2
Identifier200022640
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer
# 3
Identifier650020254
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerRR MEDICARE

VIII. Authorized Official

Name: MR. CARL BRENT SCOTT
Title or Position: OWNER
Credential: P.T.
Phone: 918-458-5115