1316052517 NPI number — EDMOND LASER INSTITUTE L.L.C.

Table of content: MISS TASHA JEAN FLADLAND (NPI 1952639213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316052517 NPI number — EDMOND LASER INSTITUTE L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDMOND LASER INSTITUTE L.L.C.
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:
Provider Other Organization Name Type Code:
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:
1316052517
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 S BRYANT AVE
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
EDMOND
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73034-6399
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-348-9797
Provider Business Mailing Address Fax Number:
405-348-9026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 S BRYANT AVE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
EDMOND
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73034-6399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-348-9797
Provider Business Practice Location Address Fax Number:
405-348-9026
Provider Enumeration Date:
08/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PEARCE
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT/MEDICAL DIRECTOR
Authorized Official Telephone Number:
405-348-9797

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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