Provider Demographics
NPI:1023490349
Name:ETHERIDGE PROSTHETICS LLC
Entity type:Organization
Organization Name:ETHERIDGE PROSTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROSTHETIST
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:ETHERIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:BOCP LP
Authorized Official - Phone:405-323-6936
Mailing Address - Street 1:2202 WESTPARK DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-4033
Mailing Address - Country:US
Mailing Address - Phone:405-701-3733
Mailing Address - Fax:405-701-3752
Practice Address - Street 1:2202 WESTPARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-4033
Practice Address - Country:US
Practice Address - Phone:405-701-3733
Practice Address - Fax:405-701-3752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-23
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKC21410224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty