=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891407649
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT SPORTS HEALTH & PERFORMANCE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2022
-----------------------------------------------------
Last Update Date | 12/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7312 NW 164TH ST STE 102
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73013-9055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-252-1650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6612 NW 148TH ST
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73142-7862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-714-2290
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | DR. GRANT FIELD
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 405-714-2290
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------