MEDICARE: LAKE COUNTRY MEDICAL SUPPLIES OF OKMULGEE, LLC

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	332BD1200X	Dialysis Equipment & Supplies (DME)
2	332BN1400X	Nursing Facility Supplies (DME)
3	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)
4	332BX2000X	Oxygen Equipment & Supplies (DME)	14-S-795	OK
5	332B00000X	Durable Medical Equipment & Medical Supplies		OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376546960
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE COUNTRY MEDICAL SUPPLIES OF OKMULGEE, LLC

Provider Business Mailing Address
First Line	:	702 S MISSISSIPPI AVE
Second Line	:
City	:	ATOKA
State	:	OK
Zip	:	74525-3324
Country	:	US
Telephone Number	:	580-889-7878
Fax Number	:	580-889-8713

Provider Business Practice Location Address
First Line	:	1180 S BELMONT AVE
Second Line	:
City	:	OKMULGEE
State	:	OK
Zip	:	74447-6308
Country	:	US
Telephone Number	:	918-756-9279
Fax Number	:	918-756-2656

Authorized Official
Title or Position	:	OWNER PRESIDENT
Name	:	RYAN RITTER
Credential	:	D.P.H.
Telephone Number	:	580-889-7800

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	05/26/2011

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