=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417080888
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DURANT PHYSICAL THERAPY & AQUATIC CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1004 N 19TH AVE BLDG 4
-----------------------------------------------------
City | DURANT
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74701-3017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-920-2231
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1004 N 19TH AVE BLDG 4
-----------------------------------------------------
City | DURANT
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74701-3017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPY ASSISTANT
-----------------------------------------------------
Name | ALYSSA ALLENE JONES
-----------------------------------------------------
Credential | PTA
-----------------------------------------------------
Telephone | 580-920-2231
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 1340
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------