Healthcare Provider Details

I. General information

NPI: 1780449165
Provider Name (Legal Business Name): TY ORTEGA H.I.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2024
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5402 SW LEE BLVD
LAWTON OK
73505-9521
US

IV. Provider business mailing address

5402 SW LEE BLVD
LAWTON OK
73505-9521
US

V. Phone/Fax

Practice location:
  • Phone: 580-536-6122
  • Fax: 580-536-6141
Mailing address:
  • Phone: 580-536-6122
  • Fax: 580-536-6141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1008
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: