Provider Demographics
NPI:1760963276
Name:SPECIALTY FACIAL PROSTHETICS LLC
Entity Type:Organization
Organization Name:SPECIALTY FACIAL PROSTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TECHNICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHARLESETTA
Authorized Official - Middle Name:M
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-595-3226
Mailing Address - Street 1:229 NW 9TH ST STE 107
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73102-2619
Mailing Address - Country:US
Mailing Address - Phone:405-595-3226
Mailing Address - Fax:405-600-6296
Practice Address - Street 1:229 NW 9TH ST STE 107
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-2619
Practice Address - Country:US
Practice Address - Phone:405-620-0880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-23
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment