Healthcare Provider Details

I. General information

NPI: 1669548533
Provider Name (Legal Business Name): EARCARE OF PONCA CITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 NORTH 14TH
PONCA CITY OK
74601
US

IV. Provider business mailing address

2010 N 14TH
PONCA CITY OK
74601
US

V. Phone/Fax

Practice location:
  • Phone: 580-718-9991
  • Fax: 580-718-9993
Mailing address:
  • Phone: 580-718-9991
  • Fax: 580-718-9993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License NumberCE569
License Number StateKS

VIII. Authorized Official

Name: TIM BRECHEISEN
Title or Position: OWNER
Credential:
Phone: 580-718-9991