Provider Demographics
NPI:1700098589
Name:BOB KEATHLEY OPTICIANS LLC
Entity Type:Organization
Organization Name:BOB KEATHLEY OPTICIANS LLC
Other - Org Name:BUDGET OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:R
Authorized Official - Last Name:KEATHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-494-2671
Mailing Address - Street 1:6025 S SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-9211
Mailing Address - Country:US
Mailing Address - Phone:918-494-2671
Mailing Address - Fax:918-496-1993
Practice Address - Street 1:6025 S SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-9211
Practice Address - Country:US
Practice Address - Phone:918-494-2671
Practice Address - Fax:918-496-1993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK020779332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100768340Medicaid
OK0727760001Medicare ID - Type Unspecified