Provider Demographics
NPI:1609046515
Name:BUST STOP
Entity Type:Organization
Organization Name:BUST STOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRASHEAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-250-0180
Mailing Address - Street 1:8270 E 71ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-2908
Mailing Address - Country:US
Mailing Address - Phone:918-250-0180
Mailing Address - Fax:918-250-8508
Practice Address - Street 1:8270 E 71ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-2908
Practice Address - Country:US
Practice Address - Phone:918-250-0180
Practice Address - Fax:918-250-8508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK4862340001Medicare NSC