Provider Demographics
NPI:1912665076
Name:SPECIALTY FACIAL PROSTHETICS LLC
Entity Type:Organization
Organization Name:SPECIALTY FACIAL PROSTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CHARLESETTA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-595-3226
Mailing Address - Street 1:229 NW 9TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73102-2619
Mailing Address - Country:US
Mailing Address - Phone:405-595-3226
Mailing Address - Fax:405-600-6296
Practice Address - Street 1:214 E LUMSDEN RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6440
Practice Address - Country:US
Practice Address - Phone:813-684-1142
Practice Address - Fax:813-681-0921
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECIALTY FACIAL PROSTHETICS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies