1023238755 NPI number — OKLAHOMA CITY VISION SOURCE

Table of content: (NPI 1023238755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023238755 NPI number — OKLAHOMA CITY VISION SOURCE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OKLAHOMA CITY VISION SOURCE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FORESTER & PITT VISION SOURCE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023238755
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3011 NW 63RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73116-3629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-840-2800
Provider Business Mailing Address Fax Number:
405-840-8242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3011 NW 63RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73116-3629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-840-2800
Provider Business Practice Location Address Fax Number:
405-840-8242
Provider Enumeration Date:
04/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FORESTER
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
405-840-2800

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2099 SCOTT FORESTER , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 2464 TRENT PITT , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100763860A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200062890A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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