Healthcare Provider Details

I. General information

NPI: 1588666473
Provider Name (Legal Business Name): LAKEPOINTE PET, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10914 HEFNER POINTE DR SUITE 100
OKLAHOMA CITY OK
73120-5066
US

IV. Provider business mailing address

10914 HEFNER POINTE DR SUITE 100
OKLAHOMA CITY OK
73120-5066
US

V. Phone/Fax

Practice location:
  • Phone: 405-488-7226
  • Fax: 405-418-0118
Mailing address:
  • Phone: 405-488-7226
  • Fax: 405-418-0118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberN A
License Number StateOK

VIII. Authorized Official

Name: MS. PAULA ALICE FULTON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 405-488-7226