Provider Demographics
NPI:1255414298
Name:SOUTHWESTERN SPORTS & INDUSTRIAL REHAB CLINC INC
Entity type:Organization
Organization Name:SOUTHWESTERN SPORTS & INDUSTRIAL REHAB CLINC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:DRAKE
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-772-3200
Mailing Address - Street 1:PO BOX 665
Mailing Address - Street 2:1400 LERA DR.
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-0665
Mailing Address - Country:US
Mailing Address - Phone:580-772-3200
Mailing Address - Fax:580-772-1061
Practice Address - Street 1:1400 LERA
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:OK
Practice Address - Zip Code:73096-2629
Practice Address - Country:US
Practice Address - Phone:580-772-3200
Practice Address - Fax:580-772-1061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK703225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1187600001Medicare ID - Type UnspecifiedMEDICARE ID NBR