Provider Demographics
NPI:1457597312
Name:SAMS OPTICAL OKLAHOMA CITY
Entity Type:Organization
Organization Name:SAMS OPTICAL OKLAHOMA CITY
Other - Org Name:SAMS OPTICAL OKLAHOMA CITY
Other - Org Type:Other Name
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:F
Authorized Official - Last Name:BERTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-631-7560
Mailing Address - Street 1:500 W I 240 SERVICE RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-4400
Mailing Address - Country:US
Mailing Address - Phone:405-778-6227
Mailing Address - Fax:405-778-6228
Practice Address - Street 1:500 W I 240 SERVICE RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-4400
Practice Address - Country:US
Practice Address - Phone:405-778-6227
Practice Address - Fax:405-778-6228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-24
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200235630AMedicaid
OK200235630AMedicaid