MEDICARE: MR. HENRY LA FUENTE BCO, BADO

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	224P00000X	Prosthetist
2	156FX1700X	Ocularist	331034873	OK
3	225000000X	Orthotic Fitter	331034873	OK
4	229N00000X	Anaplastologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	331034873	OTHER	OK	TAX ID
2	1811194368	OTHER	OK	GROUP NPI
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679520423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HENRY LA FUENTE BCO, BADO

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	04/02/2012

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Directions to “ MR. HENRY LA FUENTE BCO, BADO” Practice Location

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