Organization
LAKE COUNTRY MEDICAL SUPPLIES, LLC
Active
Other names
Complete Care Medical
Organization subpart
No
Provider details
NPI number
Authorized official
VICTOR CLAY (OWNER)
(580) 286-5022
Entity
Organization
Contact information
Practice address
744 S MISSISSIPPI AVE, ATOKA, OK 74525-3355
(580) 889-7878
Mailing address
744 S MISSISSIPPI AVE, ATOKA, OK 74525-3355
(580) 889-7878
(580) 889-8713
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
OK
332BD1200X
Dialysis Equipment & Supplies (DME)
—
—
332BN1400X
Nursing Facility Supplies (DME)
—
—
332BP3500X
Parenteral & Enteral Nutrition Supplies (DME)
—
—
332BX2000X
Oxygen Equipment & Supplies (DME)
Primary
57-S-940
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100813530A
—
OK
01
—
742803495001
BLUE CROSS BLUE SHIELD
OK
Enumeration date
05/27/2005
Last updated
06/25/2019
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