MEDICARE: ACTIVE REHAB CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1538702576
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE REHAB CLINIC

Provider Business Mailing Address
First Line	:	6929 S SOONER RD APT 43101
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73135-2739
Country	:	US
Telephone Number	:	405-209-0692
Fax Number	:

Provider Business Practice Location Address
First Line	:	8720 S PENNSYLVANIA AVE STE B
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-5237
Country	:	US
Telephone Number	:	405-209-0692
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	LATOSHIA DENISE HARDISON
Credential	:	PT, DPT
Telephone Number	:	405-209-0692

Provider Enumeration Date	:	10/22/2019
Last Update Date	:	08/14/2023

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Directions to “ACTIVE REHAB CLINIC ” Practice Location

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