Provider Demographics
NPI:1548538655
Name:FUNCTIONAL PERFORMANCE TRAINING AND PHYSICAL THERAPY, PLLC
Entity type:Organization
Organization Name:FUNCTIONAL PERFORMANCE TRAINING AND PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:CRANSTON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:405-850-1375
Mailing Address - Street 1:13512 N EASTERN AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73131-1812
Mailing Address - Country:US
Mailing Address - Phone:405-478-5333
Mailing Address - Fax:405-478-5334
Practice Address - Street 1:13512 N EASTERN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73131-1812
Practice Address - Country:US
Practice Address - Phone:405-478-5333
Practice Address - Fax:405-478-5334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-02
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT 1084261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy