MEDICARE: FYZICAL 73120, LLC

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	5393	OK

General Provider Information

NPI Number	:	1932697711
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FYZICAL 73120, LLC

Provider Business Mailing Address
First Line	:	PO BOX 720808
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73172-0808
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7415 N MAY AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-3201
Country	:	US
Telephone Number	:	405-230-6330
Fax Number	:

Authorized Official
Title or Position	:	OWNER, MANAGER
Name	:	DR. LAUREN COLLIER LAUREN
Credential	:	PT
Telephone Number	:	405-230-6330

Provider Enumeration Date	:	04/26/2018
Last Update Date	:	06/16/2018

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