Provider Demographics
NPI:1922106509
Name:SHAWNEE PEDORTHIC SERVICE, INC.
Entity Type:Organization
Organization Name:SHAWNEE PEDORTHIC SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, SECRETARY OF CORP.
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:KRIWANEK
Authorized Official - Suffix:
Authorized Official - Credentials:CPED, LPED
Authorized Official - Phone:405-275-1996
Mailing Address - Street 1:1510 N KICKAPOO AVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-4331
Mailing Address - Country:US
Mailing Address - Phone:405-275-1996
Mailing Address - Fax:405-275-0809
Practice Address - Street 1:1510 N KICKAPOO AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-4331
Practice Address - Country:US
Practice Address - Phone:405-275-1996
Practice Address - Fax:405-275-0809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100808590 AMedicaid
OK731580812001OtherBLUECROSS BLUESHIELD PIN
OK100808590 AMedicaid