MEDICARE: LA FUENTE OCULAR PROSTHETICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4631034873-001	OTHER		BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114193604
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA FUENTE OCULAR PROSTHETICS

Provider Business Mailing Address
First Line	:	1116 N ROBINSON AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73103-4918
Country	:	US
Telephone Number	:	405-236-2882
Fax Number	:	405-236-3335

Provider Business Practice Location Address
First Line	:	1116 N ROBINSON AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73103-4918
Country	:	US
Telephone Number	:	405-236-2882
Fax Number	:	405-236-3335

Authorized Official
Title or Position	:	MANAGER
Name	:	BRANDON LA FUENTE
Credential	:
Telephone Number	:	405-236-2882

Provider Enumeration Date	:	05/05/2008
Last Update Date	:	05/05/2008

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