Provider Demographics
NPI:1093080905
Name:PEDORTHIC FOOTCARE OF OKLAHOMA
Entity Type:Organization
Organization Name:PEDORTHIC FOOTCARE OF OKLAHOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED & LICENSED PEDORTHIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAEGER
Authorized Official - Suffix:
Authorized Official - Credentials:CPED, LPED
Authorized Official - Phone:405-924-7306
Mailing Address - Street 1:5100 N BROOKLINE AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-3603
Mailing Address - Country:US
Mailing Address - Phone:405-924-7306
Mailing Address - Fax:405-600-7287
Practice Address - Street 1:5100 N BROOKLINE AVE STE 330
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-3603
Practice Address - Country:US
Practice Address - Phone:405-924-7306
Practice Address - Fax:405-600-7287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK84335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier