1396155222 NPI number — REY AMEZQUITA CERTIFIED ORTHOTIST

Table of content: REY AMEZQUITA CERTIFIED ORTHOTIST (NPI 1396155222)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396155222 NPI number — REY AMEZQUITA CERTIFIED ORTHOTIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AMEZQUITA
Provider First Name:
REY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CERTIFIED ORTHOTIST
Provider Gender Code:
M

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:
1396155222
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4802 S 109TH EAST AVE
Provider Second Line Business Mailing Address:
BRACE SHOP
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74146-5822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-392-1500
Provider Business Mailing Address Fax Number:
918-392-1590

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4802 S 109TH EAST AVE
Provider Second Line Business Practice Location Address:
BRACE SHOP
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74146-5822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-392-1500
Provider Business Practice Location Address Fax Number:
918-392-1590
Provider Enumeration Date:
04/30/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 222Z00000X , with the licence number:  57 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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