Provider Demographics
NPI:1588735922
Name:OETHOTX
Entity type:Organization
Organization Name:OETHOTX
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:POLLIFRONE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-375-5200
Mailing Address - Street 1:PO BOX 35232
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-0630
Mailing Address - Country:US
Mailing Address - Phone:817-375-5200
Mailing Address - Fax:
Practice Address - Street 1:2800 E BROAD ST
Practice Address - Street 2:STE 124
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-6409
Practice Address - Country:US
Practice Address - Phone:817-375-5200
Practice Address - Fax:817-299-1786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1184210006Medicare NSC