Provider Demographics
NPI:1598799504
Name:ECHELON MEDICAL LLC
Entity Type:Organization
Organization Name:ECHELON MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KISTHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-848-5130
Mailing Address - Street 1:1430 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-9999
Mailing Address - Country:US
Mailing Address - Phone:405-848-5130
Mailing Address - Fax:405-848-5102
Practice Address - Street 1:1430 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745
Practice Address - Country:US
Practice Address - Phone:580-286-9700
Practice Address - Fax:580-286-9702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
OK25-S-1186332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5544400002Medicare NSC