=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700012614
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LITHO OF AMERICA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2009
-----------------------------------------------------
Last Update Date | 05/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3637 E. I-240 BUSINESS PARK
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-475-4661
-----------------------------------------------------
Fax | 877-769-2350
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3637 E. I-240 BUSINESS PARK
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-475-4661
-----------------------------------------------------
Fax | 877-769-2350
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF MEDICAL OPERATIONS
-----------------------------------------------------
Name | MR. LARRY W. MCELRATH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-826-4005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QL0400X
-----------------------------------------------------
Taxonomy Name | Lithotripsy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------