Provider Demographics
NPI:1598777476
Name:SOUTHERN OKLAHOMA FOOT TECHNOLOGY LLC
Entity Type:Organization
Organization Name:SOUTHERN OKLAHOMA FOOT TECHNOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:JOHNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-567-4250
Mailing Address - Street 1:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-0897
Mailing Address - Country:US
Mailing Address - Phone:918-567-4250
Mailing Address - Fax:918-567-2087
Practice Address - Street 1:RR 2 BOX 1755
Practice Address - Street 2:HWY 63A N PASSED VO TECH 1 MILE
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-9517
Practice Address - Country:US
Practice Address - Phone:918-567-4250
Practice Address - Fax:918-567-2087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========OtherTAX ID NUMBER
OK4609520001Medicare NSC