Provider Demographics
NPI:1922352780
Name:PEDIATRIC REHABILITATIVE ORTHOTIC SERVICES LTD CO
Entity Type:Organization
Organization Name:PEDIATRIC REHABILITATIVE ORTHOTIC SERVICES LTD CO
Other - Org Name:PROS
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:THIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-518-5980
Mailing Address - Street 1:480 E 141ST ST STE E
Mailing Address - Street 2:
Mailing Address - City:GLENPOOL
Mailing Address - State:OK
Mailing Address - Zip Code:74033-3550
Mailing Address - Country:US
Mailing Address - Phone:918-518-5980
Mailing Address - Fax:918-518-5982
Practice Address - Street 1:480 E 141ST ST STE E
Practice Address - Street 2:
Practice Address - City:GLENPOOL
Practice Address - State:OK
Practice Address - Zip Code:74033-3550
Practice Address - Country:US
Practice Address - Phone:918-518-5980
Practice Address - Fax:918-518-5982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200069410AMedicaid
KS200748390AMedicaid
OK6817110001OtherMEDICARE PTAN