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General NPI Number Information
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NPI Number | 1215266671
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Entity Type | Organization
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Legal Business Name | FUNDAMENTAL PHYSICAL THERAPY PLLC
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Dates
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Enumeration Date | 12/15/2009
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Last Update Date | 09/01/2015
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Provider Practice Location Address
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Address Line | 3500 S BOULEVARD SUITE A1
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City | EDMOND
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State | OK
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Zip | 73013-5486
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Country | US
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Telephone | 405-518-8118
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3542
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City | EDMOND
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State | OK
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Zip | 73083-3542
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Country | US
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Telephone | 405-513-8118
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DEBRA SUE CLARK
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Credential | DPT
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Telephone | 405-513-8118
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 821
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License Number State | OK
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