Provider Demographics
NPI:1952415382
Name:SERVICE MASTER MEDICAL LLC
Entity Type:Organization
Organization Name:SERVICE MASTER MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:MCCLANAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:405-222-4411
Mailing Address - Street 1:2101 W IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-2737
Mailing Address - Country:US
Mailing Address - Phone:405-222-4411
Mailing Address - Fax:405-222-4426
Practice Address - Street 1:2101 W IOWA AVE
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2737
Practice Address - Country:US
Practice Address - Phone:405-222-4411
Practice Address - Fax:405-222-4426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18S1025332BX2000X
OK20377335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200029110AMedicaid
5171560001Medicare ID - Type Unspecified