=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225651649
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHAWN SMITH OPTIMAL PT AND PERFORMANCE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2020
-----------------------------------------------------
Last Update Date | 06/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 336 NE 145TH PL
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73013-2152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-697-0860
-----------------------------------------------------
Fax | 877-561-7996
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 336 NE 145TH PL
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73013-2152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-697-0860
-----------------------------------------------------
Fax | 877-561-7996
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST / OWNER
-----------------------------------------------------
Name | SHAWN SMITH
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 405-755-0663
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------