Healthcare Provider Details

I. General information

NPI: 1083651806
Provider Name (Legal Business Name): NRA ADA OKLAHOMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 06/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 NW J.A. RICHARDSON LOOP
ADA OK
74820-2017
US

IV. Provider business mailing address

324 NW J A RICHARDSON LOOP
ADA OK
74820-2017
US

V. Phone/Fax

Practice location:
  • Phone: 580-421-9131
  • Fax: 580-421-9135
Mailing address:
  • Phone: 580-421-9131
  • Fax: 580-421-9135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License NumberN/A
License Number StateOK

VIII. Authorized Official

Name: MARK R FAWCETT
Title or Position: TREASURER
Credential:
Phone: 781-699-9000