Organization
LA FUENTE OCULAR PROSTHETICS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BRANDON LA FUENTE (MANAGER)
(405) 236-2882
Entity
Organization
Contact information
Practice address
1116 N ROBINSON AVE, OKLAHOMA CITY, OK 73103-4918
(405) 236-2882
(405) 236-3335
Mailing address
1116 N ROBINSON AVE, OKLAHOMA CITY, OK 73103-4918
(405) 236-2882
(405) 236-3335
Taxonomy
Speciality
Code
Description
License number
State
247200000X
Other Technician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100807050A
—
OK
01
—
4631034873-001
BCBS
—
Enumeration date
05/05/2008
Last updated
05/05/2008
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