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General NPI Number Information
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NPI Number | 1093080905
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Entity Type | Organization
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Legal Business Name | PEDORTHIC FOOTCARE OF OKLAHOMA
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Dates
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Enumeration Date | 03/12/2012
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Last Update Date | 04/12/2012
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Provider Practice Location Address
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Address Line | 5100 N BROOKLINE AVE STE 330
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City | OKLAHOMA CITY
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State | OK
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Zip | 73112-3603
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Country | US
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Telephone | 405-924-7306
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Fax | 405-600-7287
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Provider Business Mailing Address
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Address Line | 5100 N BROOKLINE AVE STE 330
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City | OKLAHOMA CITY
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State | OK
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Zip | 73112-3603
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Country | US
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Telephone | 405-924-7306
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Fax | 405-600-7287
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Authorized Official
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Title or Position | CERTIFIED & LICENSED PEDORTHIST
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Name | MR. KEVIN JAEGER
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Credential | CPED, LPED
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Telephone | 405-924-7306
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | 84
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License Number State | OK
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