=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790900678
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEARTLAND ORTHOTIC & PROSTHETIC LAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 322 W MACARTHUR ST
-----------------------------------------------------
City | SHAWNEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74804-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-214-1924
-----------------------------------------------------
Fax | 405-214-1110
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 322 W MACARTHUR ST
-----------------------------------------------------
City | SHAWNEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74804-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-214-1924
-----------------------------------------------------
Fax | 405-214-1110
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LANCE ELIOT FAULKNER
-----------------------------------------------------
Credential | BOC CP PLP02
-----------------------------------------------------
Telephone | 405-214-1924
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | C15550
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------