Healthcare Provider Details

I. General information

NPI: 1477730158
Provider Name (Legal Business Name): HUMAN PERFORMANCE CENTER 7 PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2008
Last Update Date: 09/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S MUSTANG RD
YUKON OK
73099-6777
US

IV. Provider business mailing address

740 S MUSTANG RD
YUKON OK
73099-6777
US

V. Phone/Fax

Practice location:
  • Phone: 405-494-7070
  • Fax:
Mailing address:
  • Phone: 405-494-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number2776
License Number StateOK

VIII. Authorized Official

Name: CARRIE LYNN WALLS
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: P.T.
Phone: 405-808-0445