Healthcare Provider Details

I. General information

NPI: 1376916742
Provider Name (Legal Business Name): ANKLE AND FOOT CLINIC OF ENID, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2015
Last Update Date: 11/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 E GARRIOTT RD SUITE J
ENID OK
73701-6156
US

IV. Provider business mailing address

915 E GARRIOTT RD SUITE J
ENID OK
73701-6156
US

V. Phone/Fax

Practice location:
  • Phone: 580-297-5184
  • Fax: 580-297-5187
Mailing address:
  • Phone: 580-297-5184
  • Fax: 580-297-5187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number304
License Number StateOK

VIII. Authorized Official

Name: DR. EDWARD ALEXANDER LEBRIJA
Title or Position: PODIATRIST
Credential: D.P.M.
Phone: 580-297-5184