Provider Demographics
NPI:1811194368
Name:LA FUENTE OCULAR PROSTHETICS LLC
Entity type:Organization
Organization Name:LA FUENTE OCULAR PROSTHETICS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:LA FUENTE
Authorized Official - Suffix:
Authorized Official - Credentials:OCULARIST
Authorized Official - Phone:405-236-2882
Mailing Address - Street 1:1116 N ROBINSON AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-4918
Mailing Address - Country:US
Mailing Address - Phone:405-236-2882
Mailing Address - Fax:405-236-3335
Practice Address - Street 1:1116 N ROBINSON AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-4918
Practice Address - Country:US
Practice Address - Phone:405-236-2882
Practice Address - Fax:405-236-3335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100807050AMedicaid
OK1114193604OtherNPI GROUP BCBS
OK348742200OtherDOL
OK100450270AOtherKMAP
OK1679520423OtherNPI
KS100450270BOtherKMAP
OK5200600001Medicare NSC
OK1114193604OtherNPI GROUP BCBS