Healthcare Provider Details

I. General information

NPI: 1568479871
Provider Name (Legal Business Name): JOHNSON OPTICAL DISPENSARY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 N MAIN ST SUITE A
ALTUS OK
73521-3119
US

IV. Provider business mailing address

1003 N MAIN ST SUITE A
ALTUS OK
73521-3119
US

V. Phone/Fax

Practice location:
  • Phone: 580-477-1242
  • Fax: 580-477-1249
Mailing address:
  • Phone: 580-477-1242
  • Fax: 580-477-1249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. BRENDA J LABETH
Title or Position: MANAGER
Credential:
Phone: 580-477-1242