=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740677574
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOMENTUM PHYSICAL THERAPY AND SPORTS MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2015
-----------------------------------------------------
Last Update Date | 04/20/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1430 E LINCOLN RD
-----------------------------------------------------
City | IDABEL
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74745-7343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-612-0572
-----------------------------------------------------
Fax | 580-286-1158
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1430 E LINCOLN RD
-----------------------------------------------------
City | IDABEL
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74745-7343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-612-0572
-----------------------------------------------------
Fax | 580-286-1158
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICAL THERAPIST
-----------------------------------------------------
Name | DR. CHRISTOPHER D SKELTON
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 580-612-0572
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 4514
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------