Provider Demographics
NPI:1497883391
Name:CHIMENTO, MARK (CP, LPO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CHIMENTO
Suffix:
Gender:M
Credentials:CP, LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13205 S 117TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-5203
Mailing Address - Country:US
Mailing Address - Phone:918-456-3114
Mailing Address - Fax:
Practice Address - Street 1:13205 S 117TH EAST AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-5203
Practice Address - Country:US
Practice Address - Phone:918-456-3114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK44335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
1253680001Medicare NSC