Provider Demographics
NPI:1871126383
Name:BOOMER 06, PLLC
Entity type:Organization
Organization Name:BOOMER 06, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:ELASSAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-996-0660
Mailing Address - Street 1:10921 S WESTERN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-6228
Mailing Address - Country:US
Mailing Address - Phone:405-676-5606
Mailing Address - Fax:405-676-5374
Practice Address - Street 1:10921 S WESTERN AVE STE 200
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-6228
Practice Address - Country:US
Practice Address - Phone:405-996-0660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-13
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200934220AMedicaid