Healthcare Provider Details

I. General information

NPI: 1710186994
Provider Name (Legal Business Name): LASE MED, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 12/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N POPLAR AVE STE A
BROKEN ARROW OK
74012-2337
US

IV. Provider business mailing address

1894 US HIGHWAY 50 E STE 4 #160
CARSON CITY NV
89701-3244
US

V. Phone/Fax

Practice location:
  • Phone: 918-398-9577
  • Fax: 918-398-4488
Mailing address:
  • Phone: 702-953-0267
  • Fax: 702-967-0211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number3803
License Number StateOK

VIII. Authorized Official

Name: DR. ANTONELLA CARPENTER
Title or Position: CEO
Credential: PHD
Phone: 702-953-0267