Healthcare Provider Details

I. General information

NPI: 1972782431
Provider Name (Legal Business Name): SOLE FX, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12711 E 86TH PL N SUITE 105
OWASSO OK
74055-2695
US

IV. Provider business mailing address

12711 E 86TH PL N SUITE 105
OWASSO OK
74055-2695
US

V. Phone/Fax

Practice location:
  • Phone: 918-609-6136
  • Fax: 918-609-6136
Mailing address:
  • Phone: 918-609-6136
  • Fax: 918-609-6136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number104
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number104
License Number StateOK

VIII. Authorized Official

Name: MR. MARK DOUGHERTY
Title or Position: OWNER
Credential: CPED, LPED
Phone: 918-609-6136