Healthcare Provider Details

I. General information

NPI: 1114195203
Provider Name (Legal Business Name): SUSAN LEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N CLARENCE NASH BLVD
WATONGA OK
73772-3645
US

IV. Provider business mailing address

215 N CLARENCE NASH BLVD
WATONGA OK
73772-3645
US

V. Phone/Fax

Practice location:
  • Phone: 580-623-2300
  • Fax: 580-623-7533
Mailing address:
  • Phone: 580-623-2300
  • Fax: 580-623-7533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1010
License Number StateOK

VIII. Authorized Official

Name: DR. SUSAN LEE
Title or Position: OWNER
Credential: O.D.
Phone: 580-623-2300