MEDICARE: MR. JERMAINE QUENTIN LOVE P.T.

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	225100000X	Physical Therapist	3142	OK

General Provider Information

NPI Number	:	1629269154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JERMAINE QUENTIN LOVE P.T.

Provider Business Mailing Address
First Line	:	12004 CAMELOT PL
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-6722
Country	:	US
Telephone Number	:	405-812-2082
Fax Number	:

Provider Business Practice Location Address
First Line	:	12004 CAMELOT PL
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-6722
Country	:	US
Telephone Number	:	405-812-2082
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2007
Last Update Date	:	08/08/2007

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