Provider Demographics
NPI:1134456551
Name:LESA LANDON AND AMBER LANDON
Entity Type:Organization
Organization Name:LESA LANDON AND AMBER LANDON
Other - Org Name:HAPPY FEET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:LESA
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-801-5991
Mailing Address - Street 1:PO BOX 450164
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74345-0164
Mailing Address - Country:US
Mailing Address - Phone:918-944-3442
Mailing Address - Fax:
Practice Address - Street 1:63153 EAST 290 ROAD
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344
Practice Address - Country:US
Practice Address - Phone:918-801-5991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-05
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKB5889OtherMEDICARE PTAN