Healthcare Provider Details

I. General information

NPI: 1508117698
Provider Name (Legal Business Name): GLACIER PODIATRY CLINICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2012
Last Update Date: 09/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 W 15TH ST SUITE 400B
EDMOND OK
73013-3747
US

IV. Provider business mailing address

416 W 15TH ST SUITE 400B
EDMOND OK
73013-3747
US

V. Phone/Fax

Practice location:
  • Phone: 405-285-8900
  • Fax: 405-285-8921
Mailing address:
  • Phone: 405-285-8900
  • Fax: 405-285-8921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number125
License Number StateOK

VIII. Authorized Official

Name: MR. CHAD E HUFFMYER
Title or Position: PRESIDENT
Credential:
Phone: 405-285-8900