MEDICARE: OCTOBER LYNNELL BURRIS

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	335E00000X	Prosthetic/Orthotic Supplier		OK

General Provider Information

NPI Number	:	1275480048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OCTOBER LYNNELL BURRIS

Provider Business Mailing Address
First Line	:	4021 DEBI ST
Second Line	:
City	:	ADA
State	:	OK
Zip	:	74820-4757
Country	:	US
Telephone Number	:	580-399-9305
Fax Number	:

Provider Business Practice Location Address
First Line	:	19225 STATE HIGHWAY 1E
Second Line	:
City	:	ADA
State	:	OK
Zip	:	74820-5347
Country	:	US
Telephone Number	:	580-399-9305
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/11/2026
Last Update Date	:	03/11/2026

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Directions to “ OCTOBER LYNNELL BURRIS ” Practice Location

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