MEDICARE: CROAS1 LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1598111437
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROAS1 LLC

Provider Business Mailing Address
First Line	:	300 N 5TH ST
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-4512
Country	:	US
Telephone Number	:	580-762-1291
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 N 5TH ST
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-4512
Country	:	US
Telephone Number	:	580-762-1291
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KHAJA MOHAMMED
Credential	:
Telephone Number	:	312-804-5076

Provider Enumeration Date	:	05/10/2016
Last Update Date	:	07/22/2024

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