=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568519072
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOUIS VINCE LEPAK III D.P.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2007
-----------------------------------------------------
Last Update Date | 03/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4502 E 41ST ST
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74135-2536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-660-3275
-----------------------------------------------------
Fax | 918-660-3297
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11523 S MULBERRY CT
-----------------------------------------------------
City | JENKS
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74037-3462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-299-2542
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT1581
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------