Healthcare Provider Details

I. General information

NPI: 1841437589
Provider Name (Legal Business Name): TERRELL VANZANDT CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2009
Last Update Date: 01/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 N STRONG BLVD
MCALESTER OK
74501-3847
US

IV. Provider business mailing address

1611 N STRONG BLVD
MCALESTER OK
74501-3847
US

V. Phone/Fax

Practice location:
  • Phone: 918-423-1024
  • Fax: 918-423-0611
Mailing address:
  • Phone: 918-423-1024
  • Fax: 918-423-0611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberLPO17
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberLPO17
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: