Provider Demographics
NPI:1417244195
Name:SCOTT SABOLICH PROSTHETICS & RESEARCH LLC
Entity Type:Organization
Organization Name:SCOTT SABOLICH PROSTHETICS & RESEARCH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP OF LICENSURE AND COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:CPCO
Authorized Official - Phone:512-806-2861
Mailing Address - Street 1:PO BOX 16231
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73113-2231
Mailing Address - Country:US
Mailing Address - Phone:405-841-6800
Mailing Address - Fax:405-841-9885
Practice Address - Street 1:15900 PRESTON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-3551
Practice Address - Country:US
Practice Address - Phone:877-226-5424
Practice Address - Fax:405-841-9885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKCP2626335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100812550AMedicaid
TX162712701Medicaid
TX162712701Medicaid