Provider Demographics
NPI:1538344759
Name:RETONYA J. WALTERS
Entity type:Organization
Organization Name:RETONYA J. WALTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:RETONYA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-683-5825
Mailing Address - Street 1:205 HERITAGE CT
Mailing Address - Street 2:
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434-8409
Mailing Address - Country:US
Mailing Address - Phone:918-683-5828
Mailing Address - Fax:918-683-5828
Practice Address - Street 1:102 N. 2ND
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-6601
Practice Address - Country:US
Practice Address - Phone:918-683-5828
Practice Address - Fax:918-683-5828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5459050001Medicare NSC