=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013739333
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORE PT EDMOND PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2024
-----------------------------------------------------
Last Update Date | 11/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1410 FRETZ DR
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73003-5872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-285-8477
-----------------------------------------------------
Fax | 405-285-8499
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1410 FRETZ DR
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73003-5872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-285-8477
-----------------------------------------------------
Fax | 405-285-8499
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MARICELA HARRIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 512-426-4106
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------