Provider Demographics
NPI:1356893192
Name:SOUTHEASTERN OKLAHOMA FOOT TECHNOLOGY, LLC
Entity type:Organization
Organization Name:SOUTHEASTERN OKLAHOMA FOOT TECHNOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CPED
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISIA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DERAMUS
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:918-567-7000
Mailing Address - Street 1:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-0897
Mailing Address - Country:US
Mailing Address - Phone:918-567-7000
Mailing Address - Fax:
Practice Address - Street 1:1 CHOCTAW WAY
Practice Address - Street 2:
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-2022
Practice Address - Country:US
Practice Address - Phone:918-567-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK154335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier